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ATLAS AND EPITOME 

of 

Operative Gynecology 



BY 

DR. OSKAR SCHAEFFER 

Privatdocent of Obstetrics and Gynecology in the University of Heidelberg 



AUTHORIZED TRANSLATION FROM THE GERMAN 
WITH EDITORIAL NOTES AND ADDITIONS 



Edited by 



J. CLARENCE WEBSTER, M.D. (Ecfin.), F.R.GPJE., F.R.S £. 

Professor of Obstetrics and Gynecology in Rush Medical College, in Affiliation 
with the University of Chicago ; Obstetrician and Gynecol- 
ogist to the Presbyterian Hospital. 



With 42 Colored Lithographic Plates and 
Many Text-illustrations, Some in Colors 



PHILADELPHIA, NEW YORK, LONDON 

W. B. SAUNDERS & COMPANY 

J904 




Copyright, 1904, by W. B. Saunders & Company. 



Registered at Stationers' Hall, London, England. 



ELECTROTYPED BY 
^ESTCOTT 8l THOMSON, PHILADA. 



PRESS OF 
W. B. SAUNDERS &. COMPANY. 



EDITOR'S PREFACE. 



In all medical schools students who graduate each year 
know less about gynecologic operations than about almost 
any other department of operative surgery. Amphitheater 
demonstrations are valuable only to the few who are for- 
tunate enough to be placed very near the field of opera- 
tion. In several European schools courses are given to 
limited numbers in which certain operative procedures 
are practised on genitalia removed from bodies and fast- 
ened into manikins. The value of the method is very 
restricted, even for the few students who have the oppor- 
tunity of employing it. In a large medical school, owing 
to the difficulty of obtaining material, it cannot benefit 
the great body of students. For many years teachers 
have been forced to depend largely upon pictorial repre- 
sentation in demonstrating gynecologic operations. 

The author, a well-known German teacher, has made 
a specialty of demonstrating by illustrations, and issues 
this volume as an aid to those who wish to study the sur- 
gical part of gynecology. The work represents mainly 
the experience and practice of Dr. Schaifer, and is not to 
be regarded as a comprehensive text-book. The editor 
holds himself in no way responsible for the general plan 
or for the details. 

7 



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PREFACE. 



Eight years have now elapsed since the appearance of 
the first of these atlases, the plans for which were some- 
what tentatively sketched by the publisher and the author, 
because the technic had to contend with a number of dif- 
ficulties ; but even at that time the Atlas of Gynecologic 
Technic which is now presented to the reading public was 
included in the general plan of the undertaking. Much 
patient endeavor has been expended by the author, the 
artist, and the lithographer in the preparation of this 
series of water-colors and pen-and-ink drawings. They 
are based on hundreds of photographs taken from nature, 
and, it is hoped, reproduce as faithfully and in as instruc- 
tive a manner as possible the various surgical situations 
which they are intended to illustrate. As we gained in 
experience and became accustomed to working together 
and to the peculiarities of the subject, the sketches im- 
proved in quality and gained in accuracy ; and we, there- 
fore, crave indulgence for the crudities and irregularities 
which, we are well aware, characterize some of the earlier 
pictures. A mass of original material had to be collected, 
for which I was thrown entirely on my own resources. My 
thanks are due to Mr. A. Schmitson, the artist, whose 
devotion to the work and ability, not only in handling 
the pencil and the camera, but also in entering into the 



10 PREFACE. 

technical details of the various operative procedures and 
in reproducing the colors of the tissues, it gives me the 
greatest pleasure to acknowledge. The many technical 
difficulties attending the reproduction of the pictures have 
been successfully overcome, thanks to the well-known 
energy and unwearying devotion of the publisher, Mr. J. 
F. Lehmann. 

It is the hope of the author that this atlas, as well as 
the earlier ones, will prove a useful aid in the study of 
operative gynecology by means of the object-lessons it 
contains, particularly as it is impossible to demonstrate 
the individual steps of an operation clinically to the 
majority of the students on the benches. The plan in- 
vented by vonWinckel, of using an u operative phantom," 
marks a distinct improvement in didactic methods, but 
the desiccated condition of the anatomic specimens and 
the loss of the natural color greatly detract from the value 
of the method. Pictures and " phantom " are mutually 
complementary. 

The text closely follows the illustrations. No attempt 
whatever has been made to give an exhaustive exposition 
of the subject or to include all possible complications. 

DR. O. SCHAEFFER. 



CONTENTS 



PAGE 

Introduction 17 

I. Operations that are Performed without the 

Speculum. 

Topographic and Surgical Anatomy of the Pelyic Floor 17 

Operations on the Vulva 24 

1. Complete Plastic Operation on the Perineum — Eepair of 

a Complete Perineal Laceration 26 

2. Repair of Incomplete Perineal Lacerations 33 

3. Episiotomy 43 

4. Extirpation of Portions of the Vulva or of the Hymen . 43 

5. Operations to Correct Incontinence of Urine 44 

6. Resection of the Urethra 45 

II. Operations Requiring for their Performance 

Exposure of the Vagina. 

Topographic and Surgical Anatomy of the Vagina and 

of Portio Vaginalis 46 

1. Posterior Kolporrhaphy or Kolpoperineorrhaphy ... 49 

2. Posterior Kolporrhaphy 52 

3. Anterior Kolporrhaphy 56 

4. Operation for the Narrowing of the Lumen of the Vagina 57 

5. Kolpocystotomy for the Removal of Foreign Bodies from 

the Bladder, and Operation to Unite Traumatic Vesi- 
covaginal Fistulae 59 

5 a. Dilatation of the Urethra 59 

5 6. Kolpocystotomy 61 

5 c. Method of Closing a Vesicovaginal Fistula 62 

6. Operation for the Cure of Rectovaginal Fistula .... 65 

11 



12 CONTENTS. 

PAGE 

7. Discission of the External Os 67 

8. Emmet's Operation for the Eepair of Commissural Lac- 

erations 68 

Wedge-shaped Excisions from the Cervix 69 

9. Wedge-shaped Excision from the Wall of the Ponio 

Vaginalis 69 

10. Schroder's Wedge-shaped Incision 70 

11, 12. Hysterocleisis and Xolpocleisis 71 

III. Operations Performed after Artificial Dilatation 

of the Cervical Canal of the Uterus. 

Topographic and Surgical Anatomy or the Cervix and 

Vaults of the Vagina 72 

1. Sounding the Uterus — Bloodless Dilatation of the Cervix 78 

2. Curetment (Abrasio Mucosa? ; Curettage ; Eaclage) ... 81 

3. Removal of Polyps 83 

4. Vaporization of the Uterine Cavity (Atmokausis) ... 83 

IV. Operations Performed after Dissecting away 

the Vault of the Vagina and Enlarging the 
Cervix by Operative Means. 

1. Division of the Anterior Wall of the Cervix 85 

2. Ligation of the Uterine Artery 89 

3. Supravaginal Amputation of the Cervix 92 

4. Operation for the Closure of Cervicovesical and Cervico- 

ureteral Fistulas 94 

5. Method of Opening Abscesses in the Parametria (Pelvic 

Abscess) 96 

V. Operations that Require Opening of the Vesico- 

uterine Fossa. 

1. Anterior Kolpoceliotomy 97 

2. Vaginofixation (Vaginifixura Vesicofixatio Uteri) ... 98 

3. Operations that can be Performed on the Uterus with the 

Aid of Anterior Kolpoceliotomy 101 

4. Operations on the Adnexa 102 



CONTENTS. 13 

VI. Operations that are Performed through the 

Posterior Pouch of Douglas. 

PAGE 

1. Posterior Kolpoceliotomy and Retrofixation of the Cervix 105 

2. Operative Treatment of Ectopic Gestation and its Conse- 

quences iqq 

3. Operative Treatment of Abscesses in the Pouch of Douglas 107 

VII. Operations Performed after Opening One or 
Both Peritoneal Pouches and an Entire Wall 

of the Uterus 109 

VIII. Total Extirpation of the Uterus through the 
Vagina by Opening the Anterior and Posterior 
Peritoneal Pouches Ill 

IX. Operations on the Genital Organs that Require 

a Celiotomy. 

Topography and Anatomy or that Portion of the Gen- 
ital Organs Extending into the Peritoneal 
Cavity 114 

1. The Oblique Incision in the Hypogastric-inguinal Region 121 

2. The Transverse Incision in the Suprapubic Eegion . . . 121 
8. Celiotomy with an Ordinary Median Incision through the 

Abdominal Wall , 122 

4. Abdominal Hysterectomy 125 

5. Supravaginal Abdominal Hysterectomy for Myoma . . . 127 

6. Ventrofixation of the Uterus 128 

X. Alexander* Adams Operation, Performed after 

Exposure of the Inguinal Canal. 

Topographic and Surgical Anatomy of the Inguinal 

Eegion 129 

Alexander- Adams Operation for Shortening the Eound 

Ligament 130 



Index 133 



LIST OF PLATES. 



PAGE 

Plate 1. — Kepair of a Complete Perineal Laceration 26 

Plate 2. — Repair of a Complete Perineal Laceration 28 

Plate 3. — Kolpoperineorrhaphy with Retrofixation of the Neck 48 
Plates 4-8. — Kolpoperineorrhaphy with Retrofixation of the 

Cervix 50 

Plate 9. — Anterior Kolporrhaphy (Denudation after Hegar) . . 58 

Plate 10. — High Vaginorrhaphy , 58 

Plate 11. — Removal of Foreign Body from the Bladder through 

the Dilated Urethra 60 

Plate 12. — Method of Closing a Vesicovaginal Fistula .... 62 

Plates 13, 14. — Method of Closing a High Rectovaginal Fistula . 64 
Plate 15. — Double Wedge-shaped Excision of the Cervix in 

Chronic Metritis 68 

Plate 16. — Wedge-shaped Excision in Eversion and Cervicitis . 70 

Plates 17-19. — Supravaginal Amputation of the Cervix .... 86 
Plates 20-23. — Enucleation of a Polypous Fibromyoma after 

Division of the Anterior Wall of the Cervix . 86, 88 

Plate 24. — Anterior Kolpoceliotomy 96 

Plate 25, Fig. 1. — Anterior Kolpoceliotomy 98 

Fig. 2. — Vaginifixation of the Uterus after Kolpoceli- 
otomy 98 

Plates 26-28. — Ovariotomy after Anterior Kolpoceliotomy . 98, 102 
Plates 29-33.— Total Extirpation of the Uterus through. the 

Vagina 110, 112 

Plates 34-37.— Abdominal Hysterectomy 124 

Plates 38-41. — Abdominal Hysterectomy in a Case of Myoma of 

the Uterus 126 

Plate 42. — Abdominal Hysteropexy or Ventrofixation of the 

Uterus 126 

15 




OPERATIVE GYNECOLOGY 



INTRODUCTION. 

The technic of the individual gynecologic operations 
depends very much on the methods adopted to bring the 
diseased portions into view and to prepare them for oper- 
ative intervention. It is a noteworthy fact that modern 
gynecology and its operative technic were made possible 
only by the invention of bivalve and spatular specula, 
double tenacula, and shepherd's crook hooks, with the 
aid of which the internal portions of the genitalia are 
brought into view. These inventions we owe to Simon 
and Marion Sims. 

It therefore appears to me appropriate in an atlas 
designed to represent the technic as it appears to the eye, 
to classify the operations not according to the parts of the 
organs on which they are performed, but according to 
the methods of gaining access to them for the purpose of 
operation. 

I. OPERATIONS THAT ARE PERFORMED WITHOUT 
THE SPECULUM. 

Topographic and Surgical Anatomy of the Pelvic Floor. 

The anatomic region here concerned includes, of 
course, the external genitalia in the ordinary restricted 

2 17 



18 OPERATIONS WITHOUT THE SPECULUM. 

sense of the term, the vulva, and, in addition, in a 
broader sense, the anal, syniphyseal, and inguinal regions 
of both sides. The latter are included for pathologic as 
well as for anatomic reasons, for they not only contain 
the insertions of the round ligaments which must be found 
in the operation of shortening the round ligament for the 
purpose of correcting the retroflexion of a mobile uterus, 
but also the inguinal glands which receive infective or- 
ganisms from the vulva, as well as metastatic cells from 
malignant tumors of the vulva. A portion of the vagina 
can be seen without a speculum, especially if the hymen 
has been destroyed, by simply separating the labia with 
the fingers. The internal boundary of the visible portion 
corresponds to the two folds on the walls of the vagina 
formed by the levator ani (levatores ani et trigoni urethro- 
genitalis — Waldeyer) muscles and by the approximation 
of the two columnce rugarum vagince. The line thus 
formed approximately maintains the same relation with 
the skeleton when the soft parts are relaxed or prolapsed, 
but not with the soft parts themselves. The walls of the 
vagina follow any downward pouchings of the bladder or 
rectum, and, in conditions of relaxation, it is the latter that 
form the internal boundary of the visible field. 

Assuming that the topography of the external parts is 
sufficiently well known, we shall call attention to a few 
points in connection with the surgical topography of the 
inner urethral and perineal region. 

The perineum is the most important structure that 
engages our attention, both on account of its size and of 
its important position at the outlet of the pelvis, of whose 
floor it forms part. It represents the continuation of the 



ANATOMY OF THE PELVIC FLOOR. 19 

rectovaginal septum that has increased in size and become 
reinforced by strands of strong connective and muscular 
tissue, and acts as a support for the pelvic viscera, 
directly for the ampulla of the rectum, and indirectly for 
the upper portion of the rectum, the ligaments of the 
uterus, the vault of the vagina, and the bladder, although 
these organs find their direct support in the more or less 
movable tissues of the pelvic connective tissue. (SeeAtlas 
of Obstetrical Diagnosis and Treatment, Plate 8, Fig. 18.) 

[It cannot be too strongly emphasized that the perineum 
has no distinct anatomic entity, but is the anterior portion 
of the sacral segment of the pelvic floor. It is really the 
central area of strength in the floor, being the meeting- 
place of important divisions of the pelvic fascia and of 
various muscles. — Ed.] 

The pelvic floor derives its chief strength and elasticity 
from the fasciae and from the fibers of the levator muscles, 
which separate the upper, movable portions of the viscera 
from the lower or fixed tissues. These structures are in- 
cluded in the term " supradiaphragmatic/' first employed 
by Waldeyer; while the "infradiaphragmatic" structures 
are either closely adherent to the bone, like the internal 
obturator muscles and the crura of the clitoris, or firmly 
embedded in muscular and fatty tissue, like the pars trigo- 
nalis of the urethra, the pars perinealis of the rectum 
immediately below the ampulla. A certain portion of the 
internal boundary-line of the vagina above referred to may 
also be included. The openings of the three hollow vis- 
cera are situated in the subcutaneous tissue and quite 
movable. (See Atlas of Obstetrical Diagnosis and Treat- 
ment, Plate 31, Figs. 68, 69.) 



20 OPERATIONS WITHOUT THE SPECULUM. 

This " diaphragm/' which closes the lower outlet of the 
pelvis and supports the pelvic structures, is convex on its 
lower surface. Above, it is in immediate relation with 
the intestines and is formed by the union of the visceral 
pelvic fascia and its reflection into the parietal pelvic 
fascia, which is designated the superior diaphragmatic 
fascia of the pelvis ; lower down the levator ani muscle 
and the inferior diaphragmatic fascia of the pelvis, which 
invests that muscle on its outer aspect and whose reflec- 
tion joins the fascia of the obturator interims, enter into 
the formation of the " diaphragm." 

Between these fasciae are the levator ani muscles, and 
more posteriorly, completing the diaphragm, the coccygeal 
and pyriform muscles. The levator muscle takes its 
origin in a curved line extending from the lower third of 
the symphysis across the obturator foramen as far back 
as the spine of the ischium. It divides into two por- 
tions, and, after passing to the lower third of the vagina 
and below the ampulla of the rectum, which it embraces 
in part with a loop of fibers, is inserted into the anterior 
surface of the coccyx by means of the sacrococcygeal and 
anococcygeal ligaments and directly into the lateral border 
of the bone. 

The coccygeal muscles follow the course of the sacro- 
spinal ligaments from the spine of the ischium to the 
lateral border of the sacrum and coccyx, where they are 
joined above by the pyriform muscles which have their 
origin at this point ; the latter pass out of the pelvis by 
the great sacrosciatic foramina and are inserted into the 
great trochanters. 

The levator ani muscles derive material support, both 



ANATOMY OF THE PELVIC FLOOR. 21 

laterally and from below, from the obturator fasciae and 
their muscles, which closely invest the lateral wall of the 
pelvis. In front the obturator fasciae merge into the 
fasciae of the musculus trigoni urogenitalis of Waldeyer. 
The fasciae of the bulbocavernosus, transversus perinaei, 
and other muscles of that group are much less important ; 
they are imperfectly developed, and inserted chiefly in 
loose connective tissue ; nevertheless they are intimately 
connected with the above-described fascial apparatus. 
The anococcygeal ligament is analogous to the aponeu- 
rotic trigonum urogenitah and closes the pelvic cavity 
posteriorly. (See Atlas of Obstetrical Diagnosis and 
Treatment, Plates 17 and 31, Figs. 30 and 68.) 

The hollow organs that pass through the outlet of the 
pelvis do not perforate the fasciae ; the latter, on the con- 
trary, become reflected at these points, and at the same 
time frequently give off an investment for another muscle. 
These points, therefore, represent loci minoris resistentice ; 
but the abdominal and pelvic viscera cannot descend at 
these points unless there takes place a simultaneous pro- 
lapse of the hollow organs referred to. 

Other points of diminished resistance are found in the 
intervals between the individual muscles and portions of 
muscles that make up the above-described " diaphragm," 
chiefly on the side in the lateral portions of the pelvis 
and toward the coccyx, in the sciatic foramina. These 
intermuscular clefts are covered only by loose, fatty 
connective tissue and the pelvic fascia, or by pelvic 
fascia and peritoneum. Intramuscular gaps may also 
result from injuries. 

Other natural openings are found at the points where 



22 OPERATIONS WITHOUT THE SPECULUM. 

the obturator vessels and nerves, the vessels of the 
clitoris, — i. e., the pudendal plexus between the clitoris 
and the symphysis, — emerge from the pelvis. The in- 
ferior gluteal vessels and nerves, the pudendal vessels, 
and the great sciatic nerve escape through the infrapyri- 
form foramen, — that is, the cleft between the pyriform 
and coccygeal muscles, — while the suprapyriform foramen 
gives passage only to the superior gluteal artery. 

These passages must be explored in cases of lateral or 
perineal hernias, thrombosis, abscess, metastatic tumors, 
when these processes have extended from the external 
genitalia inward and upward or from within outward. 

The larger trunks, both venous and arterial, that con- 
vey the blood into and away from the pelvis are, there- 
fore, to be sought in the localities just described ; the 
smaller branches, on the other hand, ramify chiefly on the 
lateral walls of the hollow organs. The clitoris and the 
bulbi vestibuli especially enjoy an abundant blood-supply. 
The larger branches of the internal pudendal arteries, 
accompanied by the corresponding branches of the peri- 
neal nerves {nervi labii posterioris) and the dorsal nerves of 
the clitoris, pass along the internal obturator muscle and 
the trigonum urigenitale, — in other words, in a sagittal 
direction, — and disappear on the dorsal surface to the inner 
side of the gluteus maximus and through the infrapyri- 
form foramen. 

Hence an incision beginning in the vagina and running 
between the anus and the tuberosity of the ischium, or 
the inner border of the internal oblique, even if deep 
enough to divide the levator ani muscle, cannot injure 
any large arterial or nervous trunks ; such an incision 



ANATOMY OF THE PELVIC FLOOR. 23 

would divide only branches of hemorrhoidal arteries, 
veins, and nerves, practically all of which radiate around 
the anus. 

The very numerous lymphatics of the vulva empty 
into the superficial inguinal glands. 

The group of movable infradiaphragmatic hollow 
organs at the pelvic outlet accordingly includes that por- 
tion of the urethra which is below the trigonum urogenital ; 
that portion of the vagina which comes into view when 
the labia are separated and which is situated below the 
trigonum and the levator ani muscles * and the rectum 
below these muscles and the ampulla. 

Since the lower surface of the " diaphragm of the 
pelvis " is convex, there is between it and the pelvic wall 
an empty, compressible space which is filled with connec- 
tive and fattv tissue and is known as the ischiorectal fossa. 
An outrunner from this fossa, the pubic recess, becomes 
gradually narrower as it approaches the anterior wall of 
the pelvis and ends in a sharp point at the symphysis ; 
toward the skin it is, however, covered by the trigonum 
urogenitale. As this fossa, which is filled with connective 
tissue, communicates with the openings in the diaphragm 
that have been described, pathologic processes originating 
within the latter spread by direct extension to the ischio- 
rectal fossa. (See Atlas of Obstetrical Diagnosis and Treat- 
ment, Plate 17, Fig. 30.) 

The rectum in this region is covered by a layer of 
smooth muscle-fibers, and, in addition, is encircled by 
the external sphincter ani, a voluntary muscle, the fibers 
of which are inserted in the anococcygeal ligament and in 
the center of the perineum, and mingle with fibers of the 



24 OPERATIONS WITHOUT THE SPECULUM. 

levator ani and bulbocavernosus muscles. In a similar 
manner the vagina and the urethra are surrounded by 
muscular fibers that are more or less capable of acting 
independently and run in a sagittal direction ; they are 
the transversus perinsei, bulbocavernosus, and ischio- 
cavernosus muscles. These muscles are capable of con- 
stricting the vagina, hence the name, " constrictor cunni," 
which is also applied to them. (See Atlas of Obstetrical 
Diagnosis and Treatment, Plate 31, Fig. 69.) 

[There is a difference of opinion among authors as to 
the relative importance of the fascial and muscular 
structures of the pelvic floor as regards the element of 
strength. It is generally held that the latter are most 
important, though it is highly probable that this view 
is incorrect. — Ed.] 

OPERATIONS ON THE VULVA. 

Most operations on the perineum are performed for the 
purpose of repairing solutions of continuity in the tissues 
resulting from lacerations during labor. They are per- 
formed immediately after the injury to secure primary 
repair ; or, more rarely, after the wound has begun to 
granulate, when healing by second intention is expected ; 
or a plastic operation is performed, with or without ex- 
cision of the cicatricial tissue, and with or without a flap. 
The best plan, whether for the purpose of obtaining the 
best possible healing or to make the course of the puer- 
perium as easy as possible, or to insure the proper involu- 
tion of the pelvic organs in situ, is to repair a recent 
perineal laceration without delay. Owing to the situation 
of the wound, infection is very apt to take place, while the 



OPERATIONS ON THE VULVA. 25 

active absorption of the tissues during the puerperium 
readily brings about ascending lymphatic or phlebo- 
thrombotic inflammations of the pelvic structures. The 
gaping of the vulva that later takes place not only pre- 
disposes to vaginitis, but also favors prolapse of the walls 
of the vagina ; and, if the ligamentary apparatus is not 
particularly strong, this may be followed by various forms 
of prolapsus — e.g., of vagina, rectum, bladder, uterus, etc. 

Three grades of perineal laceration are distinguished, 
according to the depth : (1) Lacerations extending as far 
as the thick mass of the perineum. As a subdivision of 
this variety I should like to mention a class of cases 
that are frequently overlooked, though pathologically of 
much importance — viz., those in which the integument 
remains intact, but the tissues give way underneath. 
(2) Lacerations extending as far as the external sphincter 
ani. (3) Complete perineal lacerations, extending into the 
rectum. A special variety is represented by the rare 
accident known as a central laceration — i. e., a laceration 
of the second degree in which the anterior portion of the 
perineum is preserved. 

As the technic of the repair of a perineal laceration of 
the second degree is the same as that employed in placing 
the final sutures for the repair of lacerations of the third 
degree, the method of primary repair of a recent tear of 
that kind will first be given. 



26 OPERATIONS WITHOUT THE SPECULUM. 

Plate i. 

Repair of a Complete Perineal Laceration. — Placing the Rectal Su- 
tures. — The Avound has the shape of a butterfly. It is held open by means 
of three double tenacula, applied at the inner angle of the vaginal tear 
and at the edge of the vestibule. The sutures, which are of catgut, are 
introduced in such a way as to be tied in the rectum. 



I. Complete Plastic Operation on the Perineum— Repair of a 
Complete Perineal Laceration. — (See Plates 1 and 2; and 
Fig. 1.) 

The wound, which is held apart with hooks or double 
tenacula, has the shape of a butterfly (Plate 1), because 
the true rectovaginal septum, which is situated higher 
up, is narrower than the lower portions of the perineum, 
which rapidly broadens out below. The latter also heals 
rapidly, while the narrow part often becomes the seat of 
small abscesses or fissures during the process of repair. 
It follows from what has been said in regard to the 
anatomy that the chief object in the operation must be to 
bring the torn ends of the muscles, especially the levator 
ani and sphincter muscles and the median aponeurotic con- 
nections between the muscles, into perfect apposition with 
one another, and not to leave broad masses of connective 
tissue between them to stretch later on. 

In placing and tying the sutures two peculiarities of 
the wound must be borne in mind : it has three openings 
through the integument, each of which must be closed 
with a row of sutures, and two of the latter meet at the 
above-mentioned narrow portion of the septum. 

The rectal sutures are first introduced after the upper 
angle of the wound in the vagina and the outer tags of 
the frenulum perinrei have been seized with three double 



Tab. /. 




REPAIR OF COMPLETE PERINEAL LACERATION. 27 

tenacula, as shown in Plate 1. As these sutures are 
inaccessible after the entire wound is closed, they are to 
be tied at once in the lumen of the rectum ; for the same 
reason an absorbable material, such as catgut, is chosen, 
or at least not a draining material like ordinary twisted 
silk. The needle must not be introduced too near the 
edge of the wound, to prevent the sutures from tearing 
through and producing stitch abscesses, thus imperiling 
the success of the operation. After the rectum has been 
thoroughly cleansed, the needle is introduced into the 
rectal mucous membrane, and, after taking in a goodly 
portion of the lateral tissues, is made to emerge in the 
wound ; it is then reintroduced in the opposite wall of 
the wound surface and brought out again in the rectum. 
By pulling on the ends of the sutures the edges of the 
wound are brought into exact apposition, and the sutures 
are then tied with a double knot, care being exercised 
that the rectal mucous membrane is not turned into the 
wound. The first suture is placed at the highest point in 
the wound — that is, at the narrowest portion of the recto- 
vaginal septum ; it is important that the suture should 
not lie too close to the vaginal mucous membrane, and 
that it be not drawn too tight, because necrosis at this 
point is followed by escape of the feces. 

Single " interrupted sutures " like those described are 
surer than a continuous suture, but they must be at least 
1 cm. apart. The last suture in this row unites the ends 
of the external sphincter ani. 

The second row of sutures closes the vaginal wound ; 
the needle is again introduced from within outward as far 
as the frsenulum perinsei ; the sutures should not be tied 



28 OPERATIONS WITHOUT THE SPECULUM. 

Plate 2. 

Repair of a Complete Perineal Laceration.— Placing the Vaginal Su- 
tures. — The rectal wound is closed. The vaginal sutures are introduced in 
a horizontal row as far as the frsenulum perinsei, and should be of catgut. 
Buried catgut sutures are introduced at the broadest portion of the 
defect. 



until they have all been placed (Plate 2). It is impor- 
tant that none of these sutures, especially at the narrow- 
est point of the rectovaginal septum, should come in 
contact with the rectal sutures. Catgut should be used, 
and the sutures should be of the interrupted kind. 

While these two rows of sutures are laid horizontally 
in the long axis of the organs, the third row must be 
placed vertically — that is, in the direction of the perineum 
(Fig. 1). It is for this reason that the vaginal sutures 
must not extend beyond the frenulum perinsei ; if they 
were to be accidentally carried beyond that point, the 
operation might result in a low perineum and a widely 
gaping vagina projecting outward. 

As the tissues in the broadest portion of the wound 
are often too massive for a single suture, it is advisable 
to introduce a few buried catgut sutures at this point 
(Werth) — in other words, to close the wound in several 
layers (" stages "). The true perineal sutures should 
include plenty of tissue at the sides, so as to bring the 
deeper portions of the perineal wound into apposition 
with one another, without subjecting them to the danger 
of necrosis. ~No pockets should ever be left in the 
tissues, as retention of the secretions is very apt to result 
in abscesses. Such recesses are readily recognized, before 
the sutures are introduced, wherever the torn or divided 



Tab. 2. 




Liih.Anst /•.' Retchhold, Miiiirhen 



REPAIR OF COMPLETE PERINEAL LACERATION. 29 

ends of muscles retract the tissues ; and these ends must 
be brought together to insure a perfect restoration of the 
perineum to its original strength. The needle, to be 
introduced in the manner prescribed, must be curved, of 
good size, and made of good steel ; it is first held at right 
angles to the surface at the edge of the wound and then 
introduced with a broad lateral sweep (Fritsch). If the 
mass of tissue is more than the needle can hold, the latter 
is brought out in the bottom of the wound and reintro- 
duced as nearly as jiossible at the same point ; this has the 
additional advantage that when the suture is drawn tight, 
the floor of the wound is pushed back. 

The material for suture in this operation should be one 
that can be allowed to remain in place for some time, 
and one that does not drain, such as silver wire, alu- 
minium-bronze (this is apt to tear through), or impreg- 
nated, non-draining thread, such as silk impregnated with 
a 10 per cent, solution of gutta-percha, as first suggested 
by the author ; celluloid twine (Braun, Pagenstecher) ; 
fil de Florence (silkworm-gut) ; reindeer-tendon ; kanga- 
roo-tendon, and the like. For buried sutures catgut, or 
at most very thin linen or silk thread, should be used ; 
the former is absorbed, the latter frays out. [There can 
be little doubt that the buried sutures should always be 
easily absorbable catgut. — Ed.] 

The success of the operation depends quite as much on 
the preparatory and after-treatment as on exactness in 
technic. 

The preliminary treatment consists in thorough evac- 
uation of the bowel, which must be begun, in the 
case of plastic operations for the repair of old perineal 



30 



OPERATIONS WITHOUT THE SPECULUM. 



lacerations, several days beforehand and encouraged by 
keeping the patient on an exclusively liquid diet. The 





Fig. 1.— Repair of a complete perineal laceration (placing the perineal 
sutures). The vaginal sutures are held up out of the way. Observe the method 
of introducing the needle ; it is applied perpendicularly to the surface near 
the edge of the perineal wound ; it is then introduced with a broad lateral 
sweep, and carried down below the floor of the wound. In the depths of the 
wound the knots of the buried catgut sutures are seen. 



parts around the operative wound, including the rectum, 
are thoroughly cleansed and disinfected, the vulvar hair 
being shaved for this purpose. The rectum often does 



REPAIR OF COMPLETE PERINEAL LACERATION. 31 

not well endure the application of corrosive sublimate; if 
a preparation of mercury is insisted upon, the oxycyanid 
should be selected, otherwise cresol soap (" Seifenkresol" ) 
may be used. 

The after-treatment consists, above all, in absolute rest 
in the dorsal position ; the woman's thighs should be 
bound, but not too tightly, so as to avoid the accumula- 
tion of secretions in the pudendal region. During the 
first few days it is well to catheterize, with the usual pre- 
cautions. [Many operators allow the patient to pass urine, 
if she can, spontaneously, the vulva and perineum being 
thereafter irrigated with an antiseptic solution or covered 
with a moist antiseptic dressing. — Ed.] If the patient 
has been properly prepared, it is usually unnecessary to 
give opium to prevent a bowel movement for five days ; 
in some cases a few drops of tincture of opium may have 
to be given after a few days. If during this period the 
diet has been principally liquid, a semisolid stool usually 
takes place at this time, either spontaneously or after the 
administration of a mild laxative. [Many prefer to in- 
troduce carefully into the anus before the first movement 
a small quantity of olive oil and glycerin. —Ed.] 

The wound is not to be touched, nor is the vagina to 
be irrigated ; it must, however, be thoroughly washed 
and carefully wiped clean after every pollution, and at 
least three times a day ; the entrance to the vagina and 
the perineal region are then covered with an antiseptic 
drying powder, such as airol, europhen, itrol, iodoform, 
iodoformogen, nosophen, vioform, or possibly dermatol. 
If the patient complains of burning or if the edges of the 
wound become swollen, lead-water or aluminium acetate 



32 OPERATIONS WITHOUT THE SPECULUM. 

may be applied, or one or two sutures may even be re- 
moved. The final removal of the perineal sutures usually 
takes place between the fifth and the eighth days, but may 
be later. Abscesses and fistula? are to be treated accord- 
ing to general surgical principles. It is to be observed 
in this connection that a recent rectovaginal fistula re- 
sponds readily to measures that stimulate granulation, 
and give a fairly good prognosis. If the woman con- 
tinues to have fever for several days, especially if she 
is a puerpera, great caution must be exercised in allow- 
ing her to get up, on account of the danger of infective 
phlebothromboses in the pelvis. 

Plastic operations for the repair of old cicatrized com- 
plete perineal lacerations — in contradistinction to primary 
perineorrhaphy in recent perineal lacerations— are per- 
formed in the same way, except that more time may be 
expended on the preparatory treatment. Denudation of 
the torn area is necessary, the cut surface having the 
butterfly shape shown on Plate 1, special care being 
devoted to dissecting out the ends of the muscles. 
[Kelly's procedure of stitching together the ends of the 
sphincter muscles with catgut is always advisable. — Ed.] 
The method of introducing the sutures and the after- 
treatment are the same as that above described. The 
woman stays in bed two or three weeks. 

The earliest appropriate date for the performance of a 
secondary operation is six weeks after delivery, or, in the 
case of women who do not nurse their infants, after the 
first menstruation, which usually occurs at this time. 

The operation of uniting already granulating perineal 
tears per secundum is more often successful than might be 



REPAIR OF INCOMPLETE PERINEAL LACERATIONS. 33 

supposed. Alarming febrile manifestations may, how- 
ever, occur as the result either of the absorption of scrap- 
ings and trimmings from the wound, or the formation of 
small abscesses which, in the author's experience, have 
always ruptured externally by a fistulous tract and ended 
in good recovery. 

The final result is necessarily the formation of a high, 
and also somewhat thickened, perineum (Fig. 1). [In 
America operators are, as a rule, averse to operating when 
the wound is granulating. — Ed.] 

2. Repair of Incomplete Perineal Lacerations. 

In the operation for the repair of perineal lacerations 
of the first and second degrees the vaginal and perineal 
sutures are placed in the same way as in the case of com- 
plete perineal lacerations already described. If the gap 
is wide, buried sutures are also used ; these must not be 
too numerous, because the wound-surfaces have enough 
to do to effect good union, without their absorptive powers 
being unduly taxed. The repair of an injury of the fossa 
navicularis under the intact integument of the perineum 
demands special care. 

The after-treatment is the same as that just described. 

Much is, however, to be said about the denudation of 
the field of operation in old cicatrized incomplete perineal 
lacerations, or. in other words, in regard to the perineo- 
plastic technic in the repair of such lacerations. (See Figs. 
2-12.) 

Lacerations of this character are rarely in the median 
line ; as a rule, they are found by the side of the posterior 
column of the vagina. Accordingly, Kiistner advised 

3 



34 OPERATIONS WITHOUT THE SPECULUM. 

lateral denudation of the wound along the course of the 
scar, although originally it had always been taught that 
the denudation should be along the median line or 
have a symmetric shape ; and even now this method is the 
one chiefly used and yields uniformly excellent results. 
The principles governing the operation depend somewhat 
on the nature of the denudation, and are as follows : 

(a) Symmetric denudations in the median line, disre- 
garding the columna rugarum — methods of Fritsch, 
Hegar, and Simon. 

(b) The same, taking the columna rugarum into con- 
sideration — methods of Bischoff, Freund, A. Martin, and 
von Winckel. [Emmet's work in this connection deserves 
special mention. — Ed.] 

Both forms (a) and (b) may, if the denudation is con- 
tinued high enough, contribute to the contraction of the 
vagina — kolpoperineorrhaphy or kolpoperineoplastic opera- 
tion. 

(c) Denudations performed in such a way as to preserve 
the partly loosened flaps (flap-plastic operation after Law- 
son Tait, Sanger, Simpson). This variety includes simple 
division (splitting) (Fritsch and Kustner). 

According to the method employed and the extent of 
the denudation downward into the vagina, or upward and 
to the sides as far as the labia minora, the resulting peri- 
neum will be broad or narrow, very high, or only moder- 
ately high. Thus a narrow high perineum, for example, 
may suffice in cases in which the walls of the vagina are 
tense and the internal genitalia retain their normal posi- 
tion, but in which the vestibular portions are separated 
and thus afford an opportunity for the production of 



HEGAR'S K0LP0PER1NE0RRHAPHY. 35 

catarrhal irritations— that is, for the entrance of germs 
from the air. The method is adapted especially for 
young women who presumably will have to bear children 
repeatedly (von WinckePs method). 

y 

Fig. 2.— Hegar's kolpoperineorrhaphy with two buried sutures. 

Hegar's kolpoperineorrhaphy, which belongs to 
this group, requires the use of instruments to expose the 
parts, as it is performed high up in the vagina,, and will 
be discussed later (Fig. 2). 

.V\c, 





Fig. 3.— Fritsch's kolpoperineorrhaphy. 



The kolpoperineoplastic operation of Bischoff, to 
which that of Freund is similar, belongs to group (b), and 
is illustrated in Fig. 4. It consists in the dissection of a 



36 OPERATIONS WITHOUT THE SPECULUM. 

flap by means of the following incisions : the first incision 
results in the formation of a circumscribed tongue-shaped 
flap in the vagina, which is allowed to remain ; a second 
curved incision, almost parallel to the first, follows the 
line of the original fraenum perinsei ; on the sides this 
incision is made to diverge as it is carried higher up, 
almost or quite as far as the labia minora ; at this point it 
is connected, by means of straight incisions, with the inner 
extremities of the vaginal incision. After the flap out- 
lined by these incisions has been dissected away, the 
figure shown in Fig. 5 is produced. Each of the two 




Fig. 4.— Bisehoff 's perineoplasty. 

lateral triangles is closed separately, so that the vagina is 
narrowed on each side. The outer convexity of the peri- 
neum is united with the tongue-shaped flap in the vagina, 
and the distal edges of the wound on either side are laid 
one on the other and secured with sutures (Fig. 5). 

If it is desired to economize tissue, the edges of the 
wound, both in the perineum and in the tongue-shaped 
vaginal flap, which contains the columna posterior, are 
undermined. 

Freund's denudation (Fig. 6) is similar, but the lateral 
triangles are carried further into the vagina and upward 
along the columna. 



KOLPOPEEIXEOPLASTIC OPERATION. 



37 




if 



Fig. 5.— Perineoplastic operation after Bischoff (see Fig. 4). Method of plac- 
ing the sutures. The upper tags of the wound, are brought out of the vagina 
with hooks. These tags are united separately, while the remaining sutures 
that have been introduced through the perineum are carried to the median 
vaginal flap and then beyond the latter to the other side. In this way the 
opposite surfaces of the wound are superimposed one upon the other when the 
sutures are tied. The lateral margins of the wound should be undermined. 
The tying of the sutures should not be begun until they are all in place, so as 
to have the opportunity of correcting any asymmetry that may have formed. 



38 OPERATIONS WITHOUT THE SPECULUM. 

If we imagine BischofFs denudation narrower and 
stretched out sideways without lateral triangles (Fig. 7), 
we shall have a slightly curved oblong area corresponding 
to the posterior commissure of the vestibule, one side of 
which is applied to the other and united to it with sutures. 
All the sutures are introduced on the convexity of the 




Fig. 6.— Freund's kolpoperineorrhaphy. 

perineum and brought out in the vagina ; here they are 
reinserted on the other side and finally brought out on the 
corresponding side of the perineal convexity. The line 
of union that results has a _[_-shape, above which the flaps 
are united after they have been reduced to half their 




Fig. 7.— Von Winckel's perineorrhaphy. 

original length. The operation, devised by von "Winckel, 
is exclusively perineoplastic, and is employed in the con- 
ditions detailed above. 

A. Martin adds to the curved incision of the commis- 
sure two superior incisions parallel to the columna pos- 
terior, extending up into the vagina to any height de- 



FLAPS AND DIVISION OF THE TISSUES. 



39 



sired, and two lateral incisions. When denudation is 
completed, the raw area resembles four outstretched 
fingers; he then closes the vaginal surfaces separately, 
and then the lateral portions of the denuded surface in 




Fig. 8.— A. Martin's posterior kolporrhaphy and perineorrhaphy with a buried 

suture. 

the region of the commissure of the vestibule, as in the 
other methods, by superposition. (See Fig. 8.) 

The underlying principles in the plastic operations 
with flaps and division of the tissues (group e) are 
the preservation of the tissues remaining, which are 
usually shortened, and the division of parts that have 




Fig. 9.— Incision to form the perineal flaps (after Lawson Tait-Siinger). 

united in a faulty manner. Lawson Tait and Sanger 
[and A. R. Simpson. — Ed.] effected this by separating 
the vagina from the rectum by moans of a transverse 
incision in the region of the perineal scar, and keep- 



40 OPERATIONS WITHOUT THE SPECULUM. 

ing these two passages apart by means of flaps. To 
form the latter, lateral incisions are made beginning 
at the extremities of the transverse incision, and run- 
ning both toward the labia and toward the anus — 
in other words, four lateral incisions running practi- 
cally perpendicular to the transverse incision, and form- 
ing two tongue-shaped flaps (Fig. 9). The walls, which 
are practically quadrangular, are united by a superficial 
and a deep row of transverse sutures (Fig. 10). The 
distal edges of the flaps then form a truncated cone. 
Fritsch makes a similar transverse division (Fig. 11), 




Fig. 10.— Introduction of the sutures after the flaps have been unfolded. 

but instead of making vertical lateral incisions to form 
flaps, he enlarges the transverse wound in the vertical 
direction with the aid of two hooks inserted one at the 
center of the vaginal, and the other at the center of the 
anal, border of the wound ; the latter is then closed by 
means of deep and superficial transverse sutures, and a 
high perineum is obtained, without any sacrifice of tissue 
(Fig. 12). 

All these operations are performed with the woman in 
the lithotomy position. After the denudation has been 
outlined with the scalpel [many operators prefer to make 
the incision with scissors. — Ed.], the flaps are dissected 



FLAPS AND DIVISION OF THE TISSUES. 



41 



off with the scissors, cutting from below upward, because 
the hemorrhage is then less profuse and does not obscure 
the operative field. When flaps are removed, they should 
be intact, so as not to leave any islands of squamous epi- 




r 



Fig. 11.— Perineoplastic operation by means of naps and division (after 
Fritsch). The vagina is separated from the rectum with a blunt dissector 
after the transverse incision has been made. 



thelium behind. The sutures run crosswise ; the needle is 
inserted and brought out again close to the edge of the 
wound, but must be carried with a wide sweep into the 
lateral tissues and below the floor of the wound. The 



42 



OPERATIONS WITHOUT THE SPECULUM. 



necessity of avoiding the formation of "dead" spaces 
has already been mentioned. The individual sutures 
must be at least \ cm. apart. Full anesthesia is de- 





■■■ 



Fig. 12.— Perineoplastic operation by means of flaps and division (after 
Fritsch). Placing the transverse sutures that close the wound, after the trans- 
verse incision has been enlarged vertically with double tenacula. The knots 
of the buried sutures are visible. 

sirable. Schleich's infiltration method can be used, but 
the resulting edema has an unfavorable influence on the 
subsequent healing of the wound. 



EXTIRPATION OF PORTIONS OF THE VULVA. 43 

3. Episiotomy. 

For the purpose of avoiding the accident of a deep 
perineal tear, or of assisting the escape of the head if the 
infant's life appears to be in danger, an oblique incision 
of varying depth is made from the vestibule of the vagina 
toward a point midway between the tuberosity of the 
ischium and the anus. The incision may be made deep 
enough to divide the levator ani muscle. In closing the 
wound the ends of that muscle, as well as the ends of 
the bulbocavernosus, must be brought into apposition — if 
necessary, by means of a buried catgut suture. The re- 
traction of these muscles draws the floor of the wound 
downward ; the wound assumes the shape of a rhomboid. 

[Episiotomy is much oftener practised in Germany than 
it is in America or in Great Britain. Except in the cases 
of extreme rigidity of the external genitals or marked 
narrowness, the operation is rarely necessary if the ob- 
stetrician employs proper manipulations during the pas- 
sage of the fetal head. Of great importance is the 
position of the woman. The greatest relaxation of the 
perineum is obtained when the limbs are placed in the 
Walcher posture or merely extended. In the lithotomy 
posture it is most tense and most liable to rupture. The 
author's incision is only one of several which are em- 
ployed. — Ed.] 

4. Extirpation of Portions of the Vulva or of the Hymen. 

This procedure may be necessary in cases of malignant 
neoplasms, kraurosis, obstinate pruritus with or without 
chronic hypertrophic folliculitis of the nympha?, and 



44 OPERATIONS WITHOUT THE SPECULUM. 

vaginismus. In the first-named condition the incision 
must be carried at least one and one-half centimeters 
beyond the recognizable limit of the diseased tissue. 
The line of incision depends on the course of the neo- 
plasm, — including diffuse, multiple, benign papillomata, — 
and in other diseases according to the extent of the tissues 
involved. In removing a hyperesthetic hymen the opera- 
tor must be careful to remove at the same time the part 
that surrounds the urethral orifice and the knob-like in- 
vagination of the hymen into that canal. For all the 
sutures silkworm-gut and very fine needles must be used; 
the latter precaution is especially important in the region 
of the clitoris and the urethra, in order to avoid hemor- 
rhage. The wound is to be dusted with an antiseptic 
drying powder. These operations require full anesthesia. 

Of the operations performed on the urethra, " dilata- 
tion " will be described in connection with the removal 
of foreign bodies by means of kolpocystotomy. 

5. Operations to Correct Incontinence of Urine. 

Gersuny's operation consists in dissecting out the ure- 
thra and twisting it 180° to 350° ; the canal, which has 
been somewhat roughly freed from the adherent connec- 
tive tissue, is then fixed in this position with sutures. 

In two cases the author obtained good results with 
Ziegenspeck's operation for narrowing the internal sphinc- 
ter of the urethra, in one case combined, however, with 
anterior kolporrhaphy. After exposing the posterior 
portion of the urethra and carefully dissecting out the 
muscular fibers, a fold is made in the latter in the sagit- 



RESECTION OF THE URETHRA. 45 

tal direction and secured with a few fine sutures. It is 
important to secure the formation of a fibrous ridge in 
the shape of a firm scar which contracts the vaginal 
mucosa in the neighborhood of this area. A fine silk- 
worm-gut suture, which serves to unite the superficial 
layers of the mucous membrane, is at the same time 
drawn through the artificial sphincter ridge. During 
the operation the degree of narrowing is controlled by 
means of a small catheter or a uterine sound. 

6. Resection of the Urethra. 

This operation is indicated in prolapse of the urethral 
mucous membrane and in the presence of urethral polypi 
or ulcers. The operation consists, in the main, of an 
incision around the posterior boundary of the urethral 
mucous membrane, the formation of flaps on each side, 
and stretching of the wound in the direction of the 
carina urethralis, so that it has a triangular shape. The 
posterior portion of the urethral mucous membrane, 
therefore, remains as a tongue-shaped flap, very much as 
in BischofPs denudation of the perineum, and the lateral 
edges of the wound are united in part with this flap and 
in part with one another by means of fine silkworm-gut 
sutures. During the operation a hook is applied on each 
side of the meatus. 



46 OPERATIONS REQUIRING EXPOSURE OF VAGINA. 

II. OPERATIONS REQUIRING FOR THEIR PER- 
FORMANCE EXPOSURE OF THE VAGINA. 

The entire extent of the vagina is brought into view 
by merely inserting a tubular glass or metal speculum, or 
an adjustable bivalve speculum provided with screws to 
regulate the width of the two parts, like the model 
originally devised by Cusco ; or by means of a grooved 
or flat speculum which depresses the posterior wall, such 
as Simon's, Marion Sims', or A. Martin's. The last are 
also known as " vagina-holders," and their efficiency may 
be increased by adding " lateral retractors." The latter 
are used in operations ; the anterior and lateral walls of 
the vagina are held aside by means of hooks or double 
tenacula, with which the upper portions of one of the 
four walls of the vagina or one of the lips of the external 
os is seized and drawn upward. For the os, a double- 
jawed Muzeux forceps is the most appropriate instrument. 

The field of operation must be fully exposed, so that it 
will not be obscured by folds and pockets or present an 
asymmetric appearance. 

Topographic and Surgical Anatomy of the Vagina and of 
the Portio Vaginalis. 

On first introduction of the speculum the pelvic dia- 
phragm described previously is spread out and pushed 
back ; a little higher up the ampulla of the rectum is 
then depressed. The anterior wall of the vagina, pre- 
senting the prominence of the urinary bladder, accord- 
ingly descends. The rectovaginal septum separates the 
two muscular lavers of the rectum and of the vagina, 



TOPOGRAPHIC AND SURGICAL ANATOMY. 47 

and consists of loose connective tissue. Opposite the 
ampulla of the rectum the septum is extremely thin, 
the distance between the lumen of. the snit and that 
of the vagina being scarcely more than 1 cm. [often 
less. — Ed.]. A band of connective tissue, the recto- 
vaginal fascia, is attached to the floor of the recto- 
uterine and rectovaginal fossa, or, in other words, to the 
peritoneal fold, and, passing between the loose connective 
tissue and the outer longitudinal muscular layer of the 
rectum, descends to the diaphragm ; the inner muscular 
layer of the rectum is circular. Two layers of smooth 
muscle are found in the vaginal wall. (See Atlas of 
Obstetric Diagnosis and Treatment, Plate 8, Fig. 18.) 

Higher up the interval between the rectum and the 
vagina is occupied by the peritoneal pouch of Douglas 
(recto-uterine and rectovaginal fossa) ; this represents a 
pocket of the peritoneum and occasionally contains ovary, 
oviducts, or loops of intestine. It varies in size in dif- 
ferent cases, and invests the posterior vault of the vagina 
and the lower third of the pelvic portion of the rectum 
as far down as the first transverse fold of the vagina, 
known as Kohlrausch's fold, at the level of the posterior 
vault of the vagina. 

Between the muscular wall of the bladder and the 
anterior wall of the vagina the vesicovaginal fascia 
passes in a similar way between the anterior peritoneal 
pouch and the "diaphragm." The structure of this con- 
nective tissue septum becomes looser and looser as the 
neck of the uterus is approached ; hence the fundus of 
the bladder can be dissected away from the vagina at and 
above this point, which corresponds with the anterior 



48 OPERATIONS REQUIRING EXPOSURE OF VAGINA. 

Plate 3. 

Kolpoperineorrhaphy -with Retrofixation of the Neck (after Hegar 
and Sanger) (see Figs. 2, 3). — Opening of Douglas' Pouch After Freshening 
up a Triangular Area on the Posterior Wall of the Vagina. — This is accom- 
plished by drawing upward the vaginal portion with a Muzeux forceps 
inserted in the posterior lip of the os ; the lateral edges of the wound are 
held aside with the aid of a series of double tenacula, which are applied 
as far up as the posterior vault of the vagina. 

vault of the vagina better than anywhere else. The 
space below this point is occupied by a denser connective 
tissue forming the trigonum Lieutaudii. The openings 
of the ureters in the bladder are situated at a point some- 
what below the external os, having passed down between 
the bladder and the vagina at the level of the vault and 
converged forward. The ureters possess a special sheath 
and lie loosely embedded in the cervicovesical connective 
tissue, so that they are quite movable ; at the level of the 
anterior lip of the os they come in immediate relation 
with the wall of the vagina, which is very thin at this 
point. 

On each side of the vagina are found rich venous 
plexuses. 

The lumen of the vagina, which in its intermediate 
portion shows the familiar H-form, assumes the shape of 
a balloon in the portio vaginalis, on account of the conic 
continuation of the cervix, which projects into the vault 
of the vagina at this point. The anterior wall of the 
vagina is extremely thin, while the posterior w T all is con- 
siderably thicker, and gives support to the portio vagi- 
nalis. The latter consists in the main of connective 
tissue, containing a few relatively sparse muscular fibers 
and numerous elastic fibers, which are united to form a 



Tab..% 




Lith. Anst F. Retchtwlil. Miinrhen. 



POSTERIOR KOLPORRHAPHY. 49 

kind of sphincter about the external os. Its outer invest- 
ment of squamous epithelium greatly resembles that cover- 
ing the vaginal walls. 

i. Posterior Kolporrhaphy or Kolpoperineorrhaphy. ; 

This is the commonest operation performed in the 
vagina. The method in most general use is that of 
Hegar. It consists in freshening up a triangular portion 
of the perineal scar and of the vagina, the base of the 
triangle corresponding in direction with the posterior 
commissure of the vestibule and the two sides running 
up into the vagina so that the apex reaches the upper 
third of that structure. Sanger combined this method 
with Fronimel's plan of fixing the cervix of the de- 
scended uterus behind and above, and obliterating the 
posterior cleft of Douglas ; hence the apex of his tri- 
angle is practically in the pouch of Douglas, which was 
opened by a posterior kolpotomy incision. This combi- 
nation of perineal plastic operation with narrowing of the 
vagina and seroso-serous retro fixation of the cervix is rep- 
resented on Plates 3 to 8, etc. I shall content myself here 
with describing only Hegar's kolpoperineorrhaphy, which 
is properly considered in this connection. (See Plate 8 
and Fig. 13 ; Plate 2 and Fig. 1.) 

After the field of operation has been freely exposed, 
the two sides of the triangle are marked out with the 
knife, from the apex to about the edge of the labia minora, 
the two lateral incisions being then united with the 
familiar convex line corresponding to the commissure of 
the vestibule. The flap of mucous membrane is dissected 
away, partly with scissors and partly by tearing from 

4 



50 OPERATIONS REQUIRING EXPOSURE OF VAGINA* 

Plate 4o 

Kolpoperineorrhaphy -with Retrofixation of the Cervix (after Hegar 
and Sanger).— The posterior pouch of Douglas has heen opened, and the 
entire operative wound in the posterior wall of the vagina is seen. 

Plate 5. 

^perineorrhaphy with Retrofixation of the Cervix (after Hegar 
'and^Sangerj. — Introduction of the Fixation Sutures. — The catgut sutures, 
A_-after passing, through the perimetrium or anterior wall of the pouch of 
Doug-las, are -introduced [ n ^ the serous membrane of the posterior wall 
of J^uglas v pouch, which overlies the sacrum and the rectum for the 
purpose of obliterating the recto-uterine fossa. 

£? r <l Plate 6. 

"?Kolpop^riineorrhaphy with Retrofixation of the Cervix (after Hegar 
and Sange/). — Introduction of the Tobacco-Pouch Suture in the Peritoneum 
of P/ouglg/ Pouch. — Tbe last fixation suture is seen in the depths of the 
The obliterating suture for the peritoneal fold of Douglas may 
be introduced after the manner of a tobacco-pouch suture. 

Plate 7. 

Kolpoperineorrhaphy with Retrofixation of the Cervix (after Hegar 
and Sanger). — Introduction of Buried Sutures in the Posterior Vault. — 
These sutures close the transverse incision and may at the same time be 
used to bring the serous membrane together. 

Plate 8. 

Kolpoperineorrhaphy with Retrofixation of the Cervix (after Hegar 
and Sanger). — Introduction of Buried Sutures along the Middle of the Vagina 
for the Purpose of Reefing the Rectocele. —The two flaps of mucous mem- 
brane on each side which result from the former steps of the operation 
have not yet been cut away. A heavy sound has been introduced into 
the rectum to guard against the lumen being included in the suture. 

without inward. Over the rectocele the septum is ex- 
tremely thin, and great care is, therefore, required in this 
region. The edges of the raw surface are then approxi- 



Tab A. 










Tab.6. 




LWuAnst.F.h Miuwhen. 



Tab. 7. 




idt hold Miifl 



POSTERIOR KOLPORRHAPHY. 



51 




Fig. 13.— Kolpoperineorrhaphy with retrofixation of the cervix (after Hegar 
and Sanger). Introduction of the transverse suture after the mucous mem- 
brane has been removed from the vagina and perineum. The edges of the 
wound have been undermined and the sutures have been introduced more 
laterally underneath the first sutures. The subsequent steps of the operation 
are shown on Plates 2 and 2a. 



52 OPERATIONS REQUIRING EXPOSURE OF VAGINA. 

mated by means of transverse sutures, catgut being used 
within the vagina and some non-absorbable and non-drain- 
ing material, such as gutta-percha silk, in the perineum. 
Over the rectocele and at the point of greatest transverse 
tension buried catgut sutures must be introduced. The 
same precautions are to be observed as in any plastic 
operation on the perineum. The edges of the wound 
may be advantageously undermined in order to get easy 
approximation. 

It is a mistake to bring about narrowing of the pos- 
terior vault of the vagina, which ought to afford a kind 
of recess for the portio vaginalis ; but immediately below 
that point the tissues may, under certain circumstances, 
require to be contracted. In the author's opinion it is, 
however, much more important to effect a lateral narrow- 
ing of the vault of the vagina and to fix the cervix high 
up and on one side (lateral hanging of the cervix) in 
cases of prolapse of the uterus, when vesicofixation and 
simple kolpoperineorrhaphy have failed to improve the 
anatomic conditions. 

A much rarer procedure is simple narrowing of the 
posterior wall of the vagina without a perineal plastic 
operation, in cases of relaxation after enterocele or recto- 
cele. This will be discussed in the next section (posterior 
kolporrhaphy). 

2. Posterior Kolporrhaphy. 

The denudation has a x shape, and this outline is 
preserved in bringing together the edges of the wound 
(Fig. 14). 

When the same condition is present in the anterior 



POSTERIOR KOLPORRHAPHY. 



53 




Fig. 14.— Posterior kolporrhaphy (a shaped). Introduction of the sutures. 
The two legs of the inverted a are united separately. One of the sutures used 
to bring together the two halves of the upper portion of the denuded surface 
is made to include the flap of mucous membrane, which projects into it, by 
introducing the suture in such a way that it passes over the flap of vagina and 
emerges on the other side of the denuded surface. The edge of the wound 
must be undermined, and the denudation must not extend into the vault of 
the vagina. 



54 OPERATIONS REQUIRING EXPOSURE OF VAGINA. 



X"- 



i. 



Fig. 15.— Anterior kolporrhaphy and obliteration of the cystocele (denuda- 
tion after Hegar). The bladder is separated from the cervix with the handle 
of the scalpel. This consists in the removal of a rhomboid flap of mucous 
membrane from the anterior wall of the vagina, a catheter being introduced 
into the bladder to protect its wall from injury. 



POSTERIOR KOLPORRHAPIIY. 



55 




Fig. 16.— Anterior kolporrhaphy and obliteration of the cystocele (denuda- 
tion after Hegar). Introduction of buried catgut sutures in the long axis of 
the vagina through the wall of the bladder and through the cervix. The su- 
tures are passed in and out of the mucous membrane several times. 



56 OPERATIONS REQUIRING EXPOSURE OF VAGINA. 

wall — i. e., when there is a cystocele — anterior kolpor- 
rhaphy is performed. 

3. Anterior Kolporrhaphy. 

Plastic operation on the anterior wall of the vagina 
for the purposes of bringing about narrowing is much 
more rare than in the case of the posterior wall, because 
relaxation of the anterior wall occurs passively only as 
a result of relaxation of the perineum. The author has, 
therefore, practically given up simple anterior kolpor- 
rhaphy and performs the operation only in the following 
combination. 

A rhomboid area is denuded, as in the original Hegar 
method (Fig. 15) ; the outlines of the area to be denuded 
are indicated by means of four double tenacula or hooks ; 
the obtuse angle is directed toward the jiortio vaginalis; 
the acute angle, with the longer sides, is directed toward 
the urinary meatus. The tenacula are applied at the 
anterior lip of the cervix, at the prominence of the 
meatus, and in the two lateral sulci, which are drawn 
forward. The bladder is then separated from the cervix 
with the finger, the scissors, or the handle of the knife 
(Fig. 15): 

The relaxation of the cystocele is first corrected by 
means of longitudinal sutures. The author has found by 
experience that the introduction of transverse sutures 
in the walls of the vagina after the usual fashion does 
not offer sufficient permanent resistance to the pressure 
of the bladder, hence the needle is inserted several times 
in the median line of the wall of the bladder at its most 
prominent point (Plate 9). The tissues are puckered in 



NARROWING THE LUMEN OF THE VAGINA. 57 

several places superficially, and the needle is carried to 
the depths of the wound, after which it is passed through 
the wall of the cervix and emerges near the edge of the 
wound. Two or three sutures are introduced in this way 
at short intervals one from the other, to avoid the termi- 
nal portions of the ureters being included in them. The 
sutures, which should be of catgut, are at once tied, so 
that the bulging of the cystocele is completely removed. 

The edges should be undermined and then brought 
together with transverse sutures (Plate 9). A strip of 
iodoform gauze is introduced into the vagina and left in 
position for a week to act as a support for the anterior 
Avail of the vagina. The woman usually urinates spon- 
taneously, but if not, she must be carefully catheterized. 
A slight admixture of blood or turbidity of the urine 
during the first few days is of no great significance. It 
is due to some catarrhal irritation which is readily cor- 
rected by means of urotropin. If incontinence had been 
preseut before, especially in old women, it usually dis- 
appears promptly. The plastic operation for the correc- 
tion of incontinence, which has been described elsewhere, 
can readily be combined with this operation. In that 
case the apex of the rhomboid representing the denuda- 
tion is carried up as far as the meatus. The patient 
should stay in bed two weeks. 

4. Operation for the Narrowing of the Lumen of the Vagina 
(after v. Winckel) (Plate 10, Fig. 17). 

This operation is performed when the ordinary kol- 
poperineorrhaphy has failed to bring about permanent cor- 
rection of the prolapsed uterus, especially in women who 



58 OPERATIONS REQUIRING EXPOSURE OF VAGINA. 

Plate 9. 

Anterior Kolporrhaphy (Denudation after Hegar).— Introduction of 
the Transverse Vaginal Suture to Close the Wound and Narrow the Vagina 
{Continuous Suture). — The longitudinal sutures first introduced have been 
tied so that the cystocele is pushed up and fixed to the cervix. The 
suture must be drawn through each time, and tension must be made by 
an assistant while the operator reintroduces the needle. At the other 
extremity of the wound a simple interrupted suture is introduced and 
tied. The free end of the continuous suture is then tied to one of the 
ends of the interrupted suture. (See Plate 28.) 

Plate 10. 

High Vaginorrhaphy ( after v. Winckeli (Fig. 17). — Introduction of the 
Narrowing Sutures. — The operative wound has the shape of three sides 
of a square, ^ > two sides are on the anterior or posterior wall of the 
vagina, and the third side on the left lateral wall. These lines are indi- 
cated by means of four double tenacula, introduced two in the anterior 
and two in the posterior wall of the vagina. Between the two arms of 
the raw area is seen the left half of the lumen of the vagina ; this is 
closed by means of an interrupted catgut suture, which is introduced in 
the arm on the anterior wall of the vagina, passes over the lumen, and 
is reinserted on the corresponding arm on the posterior wall of the 
vagina. When the knot is tied, the two arms of the figure are brought 
together and the two walls of the vagina become adherent laterally. 
The third arm of the figure is drawn together by means of interrupted 
sutures. 

are approaching the menopause. If the width of the 
upper third of the vagina for a certain distance is dimin- 
ished by performing both anterior and posterior kolpor- 
rhaphy at the same time, a circular narrowing of the 
vagina is produced which prevents not only the descent 
of the uterus, but also the inversion of the vaginal walls. 
Yon Winckel obtained a similar result by denuding an 
area on both lateral walls of the vagina in the form of a 
square with one side lacking, the two free arms of the 
figure occupying the anterior and posterior walls, while 



Tab. 9. 




Tab.W. 




■ 



JjJh. Anst F. ReicMwld, Miinchm . 



DILATATION OF THE URETHRA. 



59 



the connecting link occupied the lateral wall. The free 
sides were then sutured together (see Plate 10), and the 
lumen of the vagina on that side was thus closed to a 
distance equal to the length of the free arms of the figure. 




$ \ { J "> 

Fig. 17.— Yon Winckel's high kolporrhaphy 

The same thing was then done on the other side, so that 
an opening was left in the middle. 



5. Kolpocystotomy for the Removal of Foreign Bodies 

from the Bladder, and Operation to Unite Traumatic 

Vesicovaginal Fistula?. 

The most obvious and the usual path for the re- 
moval of foreign bodies from the bladder is through the 
urethra, which usually in such cases must be dilated. 

5a. Dilatation of the Urethra. 

The tissues about the urethra are seized with two 
hooks, one above and one below, or with four hooks 
placed symmetrically at a distance of 1 cm. from the 
urinary meatus, and successive numbers of Simon's dilat- 
ing urethral specula are then introduced until one the 
size of the little finger has been passed. It is not advis- 
able to carry the dilatation further than this size, be- 
cause it is apt to be followed by incontinence. The 



60 OPERATIONS REQUIRING EXPOSURE OF VAGINA. 

Plate ii. 

Removal of a Foreign Body from the Bladder through the Dilated 
Urethra. — The foreign body is located with the little finger introduced 
into the meatus, and a dressing forceps is passed in along the finger until 
it seizes the foreign body. If the latter has an oblong shape, it is seized 
by one extremity. The urethra is fixed by means of double tenacula 
inserted on each side. The figure shows three small incisions that are 
usually necessary. 



dilatation must be carried out gradually, especially with 
the smaller instruments, to avoid making false passages. 
To prevent the latter accident, the course of the urethra 
should first be determined by means of a catheter. The 
dilators are to be well oiled and introduced with a to- 
and-fro rotary movement. 

Dilatation may itself be a therapeutic measure — as, for 
instance, in the case of fissures at the inner orifice of the 
urethra, which are thus stimulated and heal up by granu- 
lation if the action of the sphincter is temporarily abol- 
ished. As a rule, however, dilatation is performed for 
the purpose of making intravesical operations, such as the 
removal of small tumors or foreign bodies ; or, for the 
purpose of diagnosis, either to enable the operator to 
make a bimanual examination or to introduce a small 
Simon's speculum and admit air into the bladder. Dila- 
tation for the purposes of diagnosis was performed more 
commonly in the past than it is at the present time, 
as cystoscopy without dilatation of the urethra by means 
of Casper's or Nitze's instruments, in which the source 
of light is directly introduced into the bladder with a 
catheter, lias largely taken its place. 

The fissures produced by dilatation must be carefully 



Tab. 11. 






<* 



KOLPOCYSTOTOMY. 6 1 

closed by means of fine sutures. To anticipate a tearing 
of the tissues in an undesirable direction, as toward the 
vascular region of the clitoris, small incisions are made 
above, to either side of the median line, and below in the 
median line. These also must be immediately closed 
after the operation. 

The removal of a foreign body, such as a calculus or 
a hair-pin, from the urethra, is effected, under the guid- 
ance of the little finger, with a bent dressing forceps, as 
indicated on Plate 11. [In general it is far more satis- 
factory to dilate the bladder with air in the extreme 
elevated lithotomy posture and to remove the small body 
through a short speculum. — Ed.] 

5b. Kolpocystotomy (Plate 11). 

In the event of failure by the foregoing operation, the 
bladder is opened through the vagina by means of a 
longitudinal incision, a catheter being introduced as a 
guide to the knife. Care must be exercised to avoid 
opening the urethra at its inner orifice. Before the bulg- 
ing portion of the urethra is incised, the tissues should 
be secured with four tenacula inserted above, below, and 
on either side, as in anterior kolporrhaphy. After the 
septum has been divided, the vesical mucous membrane, 
which has been made to protrude with the catheter, is held 
to one side by means of lateral sutures. The palpating 
finger can then be introduced alone or along with the 
dressing- forceps directly into the opening in the bladder, 
or the finger alone may be introduced into the dilated 
urethra. By means of this operation the removal of a 



62 OPERATIONS REQUIRING EXPOSURE OF VAGINA. 

Plate 12. 

Method of Closing a Vesicovaginal Fistula (after Simon).— The 
edges of the fistula are denuded in the form of a funnel. The needle is 
introduced from the vaginal side ; it is carried deep into the tissues, so 
as not to include the mucous membrane of the bladder, except, possibly, 
at the edge of the wound. The needle is then passed through the oppo- 
site side in the same way. Interrupted sutures are used and tied in the 
vagina. The operative field is exposed in the same manner as in ante- 
rior kolporrhaphy. 

foreign body is facilitated because the opening is larger, 
because the resistance of a spontaneously contracting 
sphincter is obviated (as by the urethral route), and be- 
cause the body can be reached by a shorter path. If the 
artificial fistula is to remain open for some time, as, for 
example, in the case of obstinate vesical catarrh, the 
edges of the wound must be closed provisionally — that is 
to say, the vesical mucous membrane must be united with 
the vagina around the opening. 

The artificial fistula is closed by means of the opera- 
tion described in the next paragraph. 

5C. Method of Closing a Vesicovaginal Fistula (after Simon 

(Plate 12) and Fritsch). 

The cicatricial edges of the original wound are first 
denuded so as to form an oval or funnel-shaped opening. 
Transverse and interrupted sutures of any material, pro- 
viding it does not drain and is not absorbable, are em- 
ployed and introduced as shown in Plate 12. The 
needle is introduced near the edge of the wound ; it is 
then carried at some depth through the lateral sub- 
mucous tissue and back in a short curve to the edge of 
the wound in the bladder, which, owing to the funnel- 



Tab. 12. 




Lith. Anst F. RetcMtold, Miwche/i. 



METHOD OF CLOSING A VESICOVAGINAL FISTULA. 63 

shaped character of the denudation, is narrower than the 
vaginal wound. The needle should pass through the 
muscular layer of the vagina, and, on emerging, should 
avoid the vesical mucous membrane. In this way, while 
the edges of the vesical mucous membrane are brought into 
close contact when the suture is drawn together, the de- 
position of urinary salts on the suture which might form 
the nucleus for foreign bodies is avoided. The sutures 
must not be drawn too tight, especially if the material 
employed is not elastic (silk), to avoid necrosis of the 
tissue ; nor should the sutures be too close together — 
they must be at least ^ cm. apart. The tying of the 
sutures should not be begun until they have all been 
introduced, so as to avoid producing asymmetry. The 
sutures in the angle of the wound do not include the 
vesical mucous membrane ; at the point of greatest ten- 
sion — that is, about the middle of the wound — the su- 
tures should be introduced with great thoroughness. After 
the completion of the operation the bladder should be 
filled with one-third of a liter of potassium permanganate 
solution to determine whether the sutures are water-tiffht. 
It is well to leave a rubber catheter in the bladder for 
several days. It may be secured with straps of adhesive 
plaster in the region of the loins, or by means of a su- 
ture passed through one of the labia minora. The cathe- 
ter should be from 18 to 25 cm. long and about as thick 
as an ordinary female catheter. The end that is intro- 
duced into the bladder must be carefully rounded off. 
It should not project more than a very short distance 
beyond the inner opening of the urethra, to avoid ulcera- 
tion of the bladder-wall from pressure, and secondary 



64 OPERATIONS REQUIRING EXPOSURE OF VAGINA. 

Plate 13. 

Method of Closing a High Rectovaginal Fistula.— After the field of 
operation has been exposed and the edges of the wound have been freshened 
up, the rectal opening is closed with catgut. The needle is introduced 
through the rectum, passed through the rectovaginal septum, and made 
to emerge again in the rectum. 



Plate 14. 

Method of Closing a High Rectovaginal Fistula. — Tying of the Rectal 
Sutures. — The sutures are all introduced before tying is begun, and the 
knots are laid in the lumen of the rectum. Afterward the edges of the 
vaginal wound are brought together over the rectal sutures. 

vesical catarrh and disturbance of the reparative proc- 
esses at the site of the scar. To effect this, the catheter 
is slowly introduced with a rotary movement, and the first 
appearance of urine should be the signal to stop its 
progress. [The most satisfactory drainage catheter is 
one with an expanded inner end. — Ed.] 

No irrigation of bladder or vagina is necessary. After 
the operation the vagina should be dusted with a disin- 
fecting powder, or a strip of iodoform may be lightly 
introduced and left in place for a few days. The woman 
remains in bed for from ten to fourteen days, when the 
wound will have healed. If ordinary silk sutures have 
been used, they must be removed at the end of a week. 
[The credit for having made known this method of 
treating vesicovaginal fistula rightly belongs to Marion 
Sims. At the present day, however, it has been widely 
displaced by the flap-splitting method. — Ed.] 

The method of closing a vesicovaginal fistula by split- 
ting the flaps was first employed by Fritsch. It is analo- 
gous to the plastic operation on the perineum by the same 



Tab. /J. 




'mt H 





LWt.Arist. A' ReicMwld, Mitiichcn . 



Tab. /•*. 






UI 






r 



m-sS^ 




A' Reiclihold . Man r hm . 



OPERA TION FOR CURE OF RECTO VA GINAL FISTULA. 65 

author that has been described elsewhere. Fritsch em- 
ployed it in cases in which, owing to extensive tissue 
destruction or scar-formation, it was impossible to obtain 
enough material for a plastic operation. A hook is in- 
serted 2 cm. above, and another 2 cm. below, the fistula. 
Between these points a longitudinal incision is made over 
the opening, and another incision laterally around the 
edges of the fistula. The edges are undermined and 
held out of the way with double tenacula, so that, as the 
undermining is continued, a muscular flap is produced 
on each side. The fistulous tract is then freshened up as 
far as the vesical mucous membrane and the two edges 
brought together by a horizontal row of sutures running 
from right to left — that is to say, each individual inter- 
rupted suture is placed by introducing the needle in a 
vertical direction. Finally, the flaps are united by 
means of transverse sutures — that is, by an ordinary 
vertical row of sutures ; in this way the sutures which 
unite the deeper tissues of the septum, say from the 
middle as far as the vesical mucous membrane, are buried, 
and these sutures should, therefore, be of catgut. If the 
vesicovaginal fistula is higher up, and the anterior lip of 
the os has suffered a median laceration, or if the fistula is 
situated altogether above the os, it is termed a vesico- 
cervical fistula. The operation for the closure of such a 
fistula requires artificial exposure of the cervical canal, as 
will be described in a subsequent paragraph. 

6. Operation for the Cure of Rectovaginal Fistula. 

The physiologic and anatomic conditions necessary for 
the cure of rectovaginal fistulse are quite different from 



66 OPERATIONS REQUIRING EXPOSURE OF VAGTNA. 

those that obtain in the case of a vesicovaginal fistula, 
and the treatment is accordingly different (Plates 13, 14). 

When the fistula is situated near the perineum, in the 
narrowest portion of the entire rectovaginal septum, it is 
found by experience that the only hope of success con- 
sists in splitting the entire perineal septum, or, in other 
words, in producing a complete perineal laceration. The 
injury is then repaired after the same methods as have 
already been described in that connection. As regards 
the fistula itself, the edges must be thoroughly denuded 
and undermined laterally, and thick flaps must be dis- 
sected away so as to provide as much elastic tissue as 
possible for the future septum instead of the old cica- 
tricial tissue, and to relieve the strain on the sutures. 

If the fistula is situated high up near the vault of the 
vagina, the edges are freshened up and undermined — that 
is to say, the vagina and the rectum are separated one 
from the other, forming an oval wound so as to enable 
the operator to introduce one row of sutures in the rectal 
wall and a separate row of sutures in the vagina, with 
the greatest possible degree of accuracy. In this way a 
broad septum will be obtained. The rectal row of sutures, 
which should consist of catgut, are tied on the inner sur- 
face of the rectum. The needle is, therefore, introduced 
into the rectal mucous membrane, near the edge of the 
wound, passed laterally through the septum wound, and 
made to emerge within the latter (Plate 13). After all 
the sutures have been introduced, they are tied one after 
the other, beginning in the upper edge of the wound, and 
the knots are pushed into the lumen of the rectum (Plate 
14). A second row of interrupted sutures is then intro- 



DISCISSION OF THE EXTERNAL OS. 67 

duced from the vagina and tied on the vaginal surface. 
The after-treatment is the same as that prescribed for 
complete plastic operations on the perineum. 

All the operations on the portio vaginalis of the uterus 
can be performed after introducing a spatular speculum 
and securing one lip of the cervix, usually the anterior, 
or the two commissures of the os, by means of tenacula. 

7. Discission of the External Os. 

This procedure is indicated in stenosis of the os, a con- 
dition that is not infrequently present when the entire 
organ is undeveloped, and is usually combined with 
catarrhal cervicitis or sterility. The cervical canal is 
usually dilated. After introducing a posterior spatular 
speculum, the anterior lip of the os is drawn forward by 
means of a tenaculum. The two lateral commissures are 
then incised to the depth of a finger's breadth; two 
approximately triangular wound-surfaces are thus pro- 
duced on each side, and these are united separately with 
a transverse suture so as to avoid adhesion of the wound- 
surfaces. Instead of introducing sutures, an iodoform 
strip may be packed between the raw surfaces and left in 
position for a week. The patient should remain in bed 
for a week. 

During labor the dilatation-period may be abridged by 
means of incisions when the edge of the os is rigid. The 
incisions are made with a long curved Siebold's scissors 
under the guidance of two fingers, either in the lateral 
commissures, although this is less advisable on account of 
the danger of hemorrhage if the incision should tear, or, 
what is better, in the anterior and posterior lips of the os. 



68 OPERATIONS REQUIRING EXPOSURE OF VAGINA. 

Plate 15. 

Double Wedge-shaped Excision of the Cervix in Chronic Metritis. — 
Showing the excisions and the method of closing the gaps by means of 
interrupted catgut sutures, the needle being introduced down to the 
floor of the wound. 

As there is usually little hemorrhage, there is no need to 
close the incisions with sutures. This is not true, how- 
ever, in the case of deep incisions of the cervix as 
employed by Diihrssen, which must be sutured. 

8. Emmet's Operation for the Repair of Commissural 
Lacerations. 

When lacerations of the commissures of the os are pro- 
duced in labor, whether on account of the rigidity of the 
external os, the use of forceps, or as the result of a lateral 
incision, the lacerations, unless they are at once united by 
sutures, heal by second intention and form scars that 
extend to the lateral vault of the vagina, and may be 
quite painful, or the scars may produce an insufficiency 
of the external os, leading eventually to the well-known 
condition of eversion of the cervical mucosa, cervicitis, 
and inflammatory hypertrophy of the mucous membrane. 

The treatment of the laceration consists in freshening 
up both the anterior and the posterior lips of the os near 
the commissures in the form of two oblong areas which 
merge into each other, the two lips being held apart with 
tenacula. The denudation is carried laterally as far as 
the scar extends on the lateral wall of the vagina. The 
two oblong wounds are then brought into apposition and 
united with interrupted catgut sutures, the needle being 
inserted from within outward as far as the external os. 



Tab.lo. 







Liih.Anst F. Hddihuld . Miinchen 



WEDGE-SHAPED EXCISIONS FROM THE CERVIX. 69 

and the sutures tied on the vaginal surface ; the needle is, 
therefore, introduced on the outer side. The denudation 
in the lateral portion of the vagina is united separately. 
[Care must be taken not to injure the ureters. — Ed.] A 
sound is then introduced into the cervical canal. An 
additional suture is passed through the edge of the com- 
missure that has been restored. The vagina is packed 
with iodoform gauze. The patient must stay in bed 
twelve days. 

WEDGE=SHAPED EXCISIONS FROM THE CERVIX. 

This method is employed in chronic metritis and to 
check inflammatory hyperplasia of the vaginal portion of 
the cervix. The excision may be made either in the wall 
of the vaginal portion only or may include the cervical 
mucosa, according to the indications. 

9. Wedge=shaped Excision from the Wall of the Portio 
Vaginalis (Plate 15). 

This may be done with or without discissions, and is 
usually performed both on the anterior and posterior lips, 
which are alternately seized on their outer side with a 
tenaculum, the posterior wall of the vagina being de- 
pressed with a spatular speculum. Two transverse 
incisions are made with a knife in the anterior lip of the 
cervix, converging so that a wedge-shaped portion of 
tissue is removed. The posterior lip is similarly dealt 
with (Plate 15). Each wound is then closed by means 
of a continuous suture or several interrupted sutures of 
catgut which must be passed through the deep portion of 
the wound. 



70 OPERATIONS REQUIRING EXPOSURE OF VAGINA. 

Plate i 6. 

Wedge-shaped Excision in E version and Cervicitis (after Schroder). 
— Excision of the inner half of each lip of the os, including the diseased 
cervical mucosa as far down as the internal os ; showing the manner of 
introducing the sutures from the internal os toward the outer edge of the 
wound, heneath the entire depth of the wound. The illustration shows 
all the interrupted catgut sutures in position. 

10. Schroder's Wedge-shaped Incision (Plate 16). 

This is used in metritic thickening of the wall of the 
vaginal portion when the diseased and everted cervical 
mucous membrane is also to be removed. The scalpel is 
thrust deep into the middle of the vaginal portion in its 
longitudinal direction, so as v to divide the cervix into two 
portions. The inner portion with the mucous membrane 
is removed by means of a second incision in the depths 
of the cervical canal, forming a right or oblique angle 
with the first incision. Thus there remains only one-half 
the thickness of the wall of the vaginal portion as far 
down almost as the internal os, the inner half of the 
mucous membrane having been removed. As most cases 
of eversion are due to laceration of the commissure, 
Schroder's wedge-shaped incision is often combined with 
Emmet's operation, which has just been described. 

The wedge-shaped wound is covered by turning the 
flaps from the wall of the vaginal portion inward and 
uniting their outer edges to the inner edge of the mucous 
membrane by sutures. The needle is inserted on the 
inner surface of the cervical canal near the internal os, 
the introduction of the needle being rendered easier by 
the splitting of the commissures. [The operation is 
much easier if it be preceded by the division of each 



Tat). W. 







Lith.Anst R Reulitwld '. Mii/irhen. 



HYSTEROCLEISIS AND KOLPOCLEISIS. 71 

commissure, the posterior and anterior portions of the 
vaginal portion being respectively dealt with. — Ed.] The 
needle must include the entire depth of the wound and is 
brought out near its outer edge. Thus there results a 
circle of radiating interrupted sutures as shown in Plate 
16, the points where the needles are introduced on the 
cervical canal being closer together than the points where 
the needles emerge on the surface of the cervix. After 
all the sutures have been placed, the tying is begun, the 
flap from the vaginal portion being at the same time 
turned inward with forceps. The lateral commissural 
incisions or Emmet's denudations are to be closed in the 
manner already described. The patient remains in bed 
for from ten to twelve days. 

ii and 12. Hysterocleisis and Kolpocleisis. 

These operations are employed as a last resort in uro- 
cervical and uretero vaginal fistulse when for any reason 
the plastic operation described in this or in the following 
groups is inapplicable or has proved unsuccessful. To 
avoid extirpation of the kidney, according to the position 
of the fistula, either the external os is denuded and the 
two lips sewed together so that they grow fast, or the 
vaginal portion is obliterated in the same way. In the 
latter case an artificial vesicovaginal fistula is first made 
by means of a kolpocystotomy, followed by suturing 
together the edges of the wound. Immediately beneath 
this opening a broad strip of the vagina is then denuded, 
and the two surfaces sew T ed together. Until firm union 
has taken place the bladder is drained with a permanent 
catheter. 



72 OPERATIONS AFTER CERVICAL DILATATION. 

Fig. 18.— Distribution of the arteries of the internal genitalia and the ureters. 
The internal spermatic artery supplies the ovaries and tubes ; the branches of 
the spermatic artery anastomose with the uterine artery on both sides at the 
lateral margin of the uterus. The uterine artery, a branch of the hypogastric, 
crosses the ureter at the level of the supravaginal portion of the cervix, and 
from this point the cervicovaginal artery is given off. The main trunk passes 
along the lateral border of the uterus and to the fundus and in its course gives 
off numerous branches. T, tube; Or., ovary; Lg. r.. round ligament; Ur., 
ureter ; E., kidney; UL, uterus. 

These artificial atresias are usually followed by serious 
consequences ; the menstrual flow is forced to take the 
way of the bladder and urethra, and the urine is apt to 
deposit incrustations on the walls of the vagina, with the 
result that decomposition of the urine and cystitis usually 
develop. 

III. OPERATIONS PERFORMED AFTER ARTIFICIAL 
DILATATION OF THE CERVICAL CANAL OF 
THE UTERUS. 

Topographic and Surgical Anatomy of the Cervix and 
Vaults of the Vagina. 

The anterior and posterior vaults of the vagina present 
certain differences in their development, in their anatomy 
and histology, in their topographic anatomy, and in their 
pathology. The anterior vault is flat, the posterior is a 
true pouch, a kind of receptacle for the vaginal portion 
of the cervix, for the sexual act, for the evacuated 
menstrual fluid, and for the descending head in 
labor. (See Atlas of Obstetrical Diagnosis and Treat- 
ment, Fig. 32, Plate 19.) 

The anterior vault in the non-gravid condition is not in 
relation with the anterior peritoneal pouch ; the wall of 
the posterior vault, on the other hand, is covered by the 




Fig. 18. 



74 OPERATIONS AFTER CERVICAL DILATATION. 

serous membrane of the posterior pouch of Douglas. The 
latter usually extends more deeply than the vaginal vault, 
and in infantile genitalia it extends further down the 
posterior vaginal wall than in the adult. W r e have, there- 
fore, at the posterior vault an extremely thin mucous, 
muscular, and connective-tissue septum which divides 
the vagina from the peritoneal cavity. The connective 
tissue which forms a subserous layer in the posterior wall 
of the cervix is loose for some distance (Fig. 18, p. 73). 
At the level of the internal os, however, the serous mem- 
brane is found to be densely adherent to the outer mus- 
cular layer of the uterus. 

In front, on the other hand, the loose connective-tissue 
septum projects above the internal os, that is, about four 
or five centimeters above the vaginal portion of the 
cervix. In this region the bladder is adherent to the 
anterior vault of the vagina and to the cervical wall as 
far up as a point a little higher than the internal orifice ; 
the connective tissue is loosest in women who have borne 
children, and most firm in women who have in the past 
suffered from inflammation of the septum or parametro- 
cystitis. [Inflammatory deposits are rarely found between 
the cervix and bladder. — Ed.] This portion of the 
bladder forms a diverticulum contiguous above with the 
trigonum Lieutaudii — that is to say, the region where the 
ureters and the urethra have their orifices. The loose 
attachment of the plica peritonei to the uterus, at the 
bottom of the vesico-uterine fossa, is on a level with the 
point of attachment of the bladder and only a little lower 
than the solid fibrous tissue uniting the serous membrane 
with the wall of the uterus ; here also the conditions in 



TOPOGRAPHIC AND SURGICAL ANATOMY. 75 

the main are different from those that obtain in the recto- 
uterine (or rectovaginal) peritoneal fossa. 

On each side the cervix is closely surrounded by con- 
nective tissue which contains elastic fibers, muscle-fibers, 
and dense bands of fibrous tissue traversed by blood- 
vessels, forming the true parametria. This tissue forms 
the base of each peritoneal fold known as the broad liga- 
ments. (Compare Atlas of Obstetrical Diagnosis and 
Ireatment, Plate 17.) 

This connective tissue, therefore, shares with the vaginal 
connective tissue in its blood supply, which is most 
important in this region as the chief arteries of the inner 
genitalia, which also in large part supply the vagina, and 
enter the tissue of the uterus at this point (Fig. 18). The 
main trunk of the uterine artery passes horizontally 
toward the supravaginal portion of the cervix, after 
crossing the ureter, which has a forward direction, at a 
point about 2 cm. distant from the wall of the cervix. 
If the lateral vaginal vault is opened in order to reach 
this point of intersection, the cervicovaginal artery, 
which is given off at a sharp angle, is first encountered, 
while the main vessel makes a right angle and passes 
toward the fundus. In its upward course to the fundus 
it makes numerous bends and is surrounded by a rich 
network of veins and gives off numerous branches to the 
uterine wall ; finally the artery takes a recurrent course 
along the tube and anastomoses with the ovarian artery. 
The bifurcation of the two diverging branches of the 
artery is near the intersection of the uterine artery with 
the ureter. The ureter at this point is found 2 cm. from 
the wall of the cervix ; from this point it passes forward 



76 OPERATIONS AFTER CERVICAL DILATATION. 

along the intermediate portion of the cervix and is then 
only 1 cm. from the lateral wall ; after that it enters the 
loose cervicovesical connective tissue. Along the cervix 
the ureter is placed between the venous plexuses of the 
uterus and those of the bladder and vagina. 

Most of the veins and lymph-vessels are found in the 
subserous layer at the posterior aspect of the uterus, cor- 
responding to the origin of the adnexa. From these 
points the veins accompany the arteries in their lateral 
course and form the uterovaginal plexuses ; at the level 
of the external os they unite to form the uterine veins 
and communicate with the vesicovaginal plexuses. The 
lvmphatic vessels, on the other hand, pass both from the 
cervix and from the vagina to the hypogastric lymph- 
glands (lymphoglandulse hypogastrics i, which are 
situated in the angles between the external iliac and 
hypogastric arteries. (See Atlas of Obstetrical Diagnosis 
and Treatment, Plate 35, Figs. 77, 78.) 

The cervix extends from the internal os, a narrow 
canal about 1 cm. in length, to the external os, being 
traversed by the spindle-shaped and gradually enlarging 
cervical canal. "We distinguish the "supravaginal" por- 
tion and true vaginal portion, or "portio vaginalis" 

The entire wall of the cervix consists in the main of 
various kinds of connective-tissue fibers containing com- 
paratively few muscular fibers; these pass directly from 
both the anterior and the posterior vault of the vagina 
and in part return from the os to the muscular layer in 
the vagina. Others pass over into the broad and utero- 
sacral ligaments, reinforced by fascia-like strands of con- 
nective tissue that run along the vessels through the 



TOPOGRAPHIC AND SURGICAL ANATOMY. 77 

broad ligaments and contribute not a little to the elastic 
fixation of the uterus (Fig. 19). 




"N 



R 



Ig.R.w. 



\ 



y- 



Zg.l.d. 



'C^^cr. 



Lg, I. s. 



Tsch. 



Lg.Vw 



*J 



Obi 



V 



Fig. 19.— Schematic representation of a cross-section of the pelvis at the level 
of the internal os, for the purpose of showing the fibrous ligamentary appa- 
ratus. The cervix (C. U.) is supported by six fibrous ligamentary bands which 
connect the structure with other organs as follows : Two pass forward (Lg. V. u.) 
to the bladder ( V) and to the os pubis (P) ; two pass laterally to the walls of the 
pelvis (Jsch.) in the base of the broad ligaments (Lxj. I. d, Lg. I. s.) ; while two 
others pass backward (Lg. E. a.) to the rectum (E) and sacrum (S). These liga- 
mentous bands are accompanied by smooth muscle-fibers ; the intervals be- 
tween them are filled in part by loose connective tissue and in part by peri- 
toneal tissue. These spaces are bounded externally by the pyriform (Py.) and 
internal obturator (Obt.) muscles. 



Operations that are performed after bloodless dilatation 
of the cervical canal include accurate probing and digital 



78 OPERATIONS AFTER CERVICAL DILATATION. 

examination of the uterus, curettage (abrasio mucosae and 
raclage), the removal of remains of the ovum, of mucous 
polyps, fibrous polyps, foreign bodies, and, finally, the 
employment of atmokausis (local steam bath). 



i. Sounding the Uterus. Bloodless Dilatation of the Cervix. 

Dilatation may be performed rapidly or gradually, both 
on the gravid and on the non-gravid organ. In the latter 
case the quick operation is performed by the introduction 
successively of graduated hard-rubber (Hegar) or metal 
(Fritsch) sounds or by introducing dilating instruments 
constructed on the principle of a glove-stretcher. The 
operation must be performed with due care. The vault 
of the vagina having first been disinfected, the smallest 
sound is introduced with slow rotary movements (Plate 
21). To guard against injuring the mucous membrane 
with the dilating sounds (especially those that are pointed) 
and against the production of a false passage or even 
dangerous perforation, the direction of the uterine canal 
must first be accurately determined with the aid of a 
probe. Especially must it be determined whether the 
internal os is surrounded by concave valves with the 
concavity pointing toward the vagina, as the dilating 
sounds are particularly apt to catch in structures of this 
kind. The probe, after having been thoroughly dis- 
infected, is carefully introduced after the insertion of a 
vaginal speculum, the position of the uterus having first 
been determined by bimanual examination. Special care 
is necessary in carrying the sound to the fundus to detect 
a perforation of the uterine wall. In women who have 



SOUNDIXG THE UTERUS. 79 

borne children the distance between the internal and ex- 
ternal os is, on the average, from 2.5 to 3 cm. ; the 
distance from the internal os to the fundus is 4 to 4.5 
cm., so that the whole length of the organ is, on the 
average, 6^- to *l\ cm. ; in virgins the same measurements 
are 2.5 -f- 3 = 5.5 cm. 

Gradual dilatation may be effected by introducing iodo- 
form gauze, laminaria, or other tents. A speculum is 
introduced into the vagina, the anterior lip of the os is 
seized, and the smallest tent is introduced into the 
internal os, or, if that is impossible, as far as the internal 
os ; it is then packed tight with gauze and allowed to 
remain in place from six to twelve or twenty-four hours, 
according to the body-temperature. To prevent infec- 
tion, the tents must be kept for weeks beforehand in 
a mixture of iodoform, ether, and alcohol ; or they must 
be boiled for a few minutes in a 5 per cent, solution of 
carbolic acid. After the first tent has been in place for a 
number of hours, the internal os begins to yield and a 
thicker tent and finally several thicker tents may be 
introduced, until the cervical canal admits a finger. The 
removal of greatly swollen tents is often very difficult; 
if the internal os has been spasmodically contracted and 
the tent has been reduced to a pulpy mass so that it 
cannot be seized with instruments, its removal may then 
require several deep incisions. [Dilatation with tents has 
been widely abandoned in recent times. — Ed.] 

The cervical canal may be rapidly dilated during labor 
by inserting first one and then two and finally the remain- 
ing fingers into the cervical canal (accouchement 
force), until the presenting part can be brought down or 



80 OPERATIONS AFTER CERVICAL DILATATION. 

a leg can be seized. Dilatation may also be effected by 
hard-rubber dilators. Other methods, however, such as 
tamponade with glycerin-iodoform gauze or the intro- 
duction of dilatable rubber bags (metreurynter) of 
gradually increasing sizes into the cervical canal or above 
the internal os are to be preferred in the case of gravid 
or parturient women (Barnes, Fehling, and Champetier 
de Ribes). 

The Barnes bags, in either small or medium sizes, are 
violin-shaped and provided w T ith a rubber tube through 
which the bag may be distended with an antiseptic or 
aseptic (non-poisonous) fluid. By means of this tube, 
which may be hung over the foot of the bed and weighted 
with one or two pounds, a degree of traction can be 
exerted which, together with the distending pressure, 
suffices to complete the dilatation of the os within a short 
time — say half an hour (Maurer, Diihrssen). 

The method of introducing the metreurynter is as 
follows : After bringing down and fixing the vaginal 
portion of the cervix and disinfecting the cervical canal, 
the latter is dilated with the small- and medium-sized 
metal dilators, and the rubber bulb, which has been pre- 
viously sterilized by boiling, is held in a large dressing 
forceps with smooth jaws and introduced as far as the 
internal os. The metreurynter is then distended with a 
sterile or feebly antiseptic fluid by means of the tube 
attached to it. Lysol should not be used, as it macerates 
the rubber. The vault of the vagina is packed with 
sterile cotton, both to expedite the dilatation and relaxa- 
tion of the cervix and to prevent the escape of the rubber 
bulb. After a few hours a larger bulb is introduced, and 



CURETMENT. 81 

this is repeated at intervals until the desired degree of 
dilatation has been secured. In some women the pro- 
cedure has the disadvantage that while the os is dilated 
the fundus of the uterus is not stimulated to contract; 
instead, a spasmodic stricture may be produced at the 
internal os, causing a rapid contraction of the latter as 
soon as the rubber dilator is removed. 

After the internal os has been sufficiently dilated, the 
cavity of the uterus can be examined by palpation, 
remains of membranes can be removed with the finger, a 
procedure that, under certain circumstances, is to be pre- 
ferred to curetment for diagnostic purposes. But even 
direct palpation does not always secure against error, as 
is shown by Werth's case, in which a malignant growth 
of the chorion was separate from the decidua, which was 
found to be entirely benign on histologic examination, so 
that curetment or palpation of the uterus might have 
failed to reveal the necessity for a radical operation. A 
total extirpation of the uterus was nevertheless performed 
on account of the history and of the subsequent course of 
the disease, which was marked by atypical hemorrhages. 
According to A. Martin, direct palpation does not even 
enable one to determine whether small multiple myomata 
have been properly enucleated. 

2. Curetment (Abrasio Mucosae; Curettage; Raclage). 

This operation is performed for the purpose of obtain- 
iug specimens of the mucous membrane from the cavity 
of the uterus for examination and for the purpose of 
removing diseased endometrium or retained secundines. 



82 OPERATIONS AFTER CERVICAL DILATATION. 

As the uterine wall in subinvolution of the organ may be 
abnormally soft, curetment must be performed with the 
following definite precautions : The length of the uterine 
cavity must first be determined with a probe, or, since 
preliminary dilatation is usually necessary, with a dilator ; 
the curet should be blunt at the end, and its cutting-edge 
should not be too keen. The instrument is introduced 
very cautiously as far as the fundus, and drawn down 
with a steady, even movement to the internal os. Suc- 
cessive strips of the mucous membrane are thus removed 
at each stroke of the curet. First the anterior, then the 
posterior, wall, then the two narrow sides, and finally the 
fundus, are to be curetted. Before terminating the opera- 
tion the uterine cavity is wiped out but not irrigated, 
unless the operator is certain that no perforation has been 
made. The Fritsch-Bozemann double catheter is the best 
instrument for irrigation. To make sure that there is no 
perforation, the uterus can be examined with the hand 
applied to the outside of the abdomen. [This is not at 
all a reliable procedure. — Ed.] 

The operation is terminated by packing the uterine 
cavity with sterile iodoform gauze, which remains in place 
twenty-four hours. The woman must stay in bed a week. 
If the uterine muscle is flaccid and hemorrhage continues 
to recur, a styptic should be applied to the cavity imme- 
diately after curetment, and, if necessary, at some future 
time. To remove secundines that cannot be taken out 
with the finger, an abortion forceps or broad dressing 
forceps is necessary. 



VAPORIZATION OF THE UTERINE CAVITY. 83 

3. Removal of Polyps. 

Mucous polyps growing from the mucous membrane 
may be twisted off with a polyp forceps or ligated at the 
base and then removed. It is well to follow the operation 
with curetment and the application of styptics to the 
cavity. 

Fibrous polyps are not infrequently regularly "de- 
livered " after spontaneous dilatation of the cervix. In 
other cases the cervix is dilated artificially and the tumor 
enucleated with the finger, the base being packed with 
sterilized ferripyrin or chlorid of iron gauze. If addi- 
tional prominent tumors are felt by the palpating finger, 
they must be seized with an instrument and loosened with 
the finger. Large polyps are to be removed in sections. 
The instrumental procedures should be carried out under 
the guidance of the palpating finger. 

4. Vaporization of the Uterine Cavity (Atmokausis). 

This is a method recently introduced by Sneguirew and 
developed by Diihrssen and Pincus ; the latter has devised 
a number of improved instruments. It is used to arrest 
metrorrhagia and menorrhagia, when the condition has 
resisted all other methods of treatment, when curetment 
and cauterization are impossible, and a radical operation 
is not necessary. The treatment of obstinate relaxation 
of the uterus and of chronic metritis without disease of 
the adnexa in multipara? has been successfully carried out 
with the aid of atmokausis.' The method has also been 
used in a series of cases by the author himself, but there 
is as vet no unanimity of opinion as to its value. That 
vaporization is a sovereign remedy against uncontrollable 



84 OPERATIONS AFTER CERVICAL DILATATION. 

hemorrhage at the climacteric cannot be doubted, dissent- 
ing opinions to the contrary notwithstanding, as the 
efficiency of the treatment is vouched for by authorities 
like Fritsch and von Winckel. 

The author has used vaporization for three years in 
about 150 cases ; his method, based on that experience, is 
as follows : Twenty-four hours before vaporization a 
moderately large laminaria tent is introduced. Before the 
application of the steam the vagina and the uterine 
cavity are carefully cleansed both mechanically and with 
antiseptic solutions ; the anterior and posterior walls of 
the vagina are covered with thin moist pads of cotton, and 
the grooved speculum, which is introduced, is similarly 
padded. The pad covering the anterior wall of the 
vagina and urinary meatus is held in place by the 
Muzeux forceps, which fixes the anterior lip of the os. 
The catheter, which is provided with a cervix protector 
consisting of " celluvert," is then introduced, the stop- 
cock which admits the steam being closed. The latter 
may have a temperature ranging between 102° and 
120° C. (215° and 248° F.), according to the object of 
the procedure. The double catheter, which has been 
previously sterilized, must be kept in a cool aseptic 
solution to prevent its producing too great a heating 
effect by contact. 

The stop-cock is now opened, and the steam, which 
rapidly condenses, rushes into the uterine cavity. The 
uterus contracts in a short time, and this contraction, as 
the author and his assistants have determined, is followed 
at first by retardation of the pulse, then by its entire 
cessation, and after that by increased frequency and 



ENLARGING THE CERVIX BY OPERATIONS. 85 

reduction in volume ; at the same time a distinct fall in 
the blood-pressure at the radial artery may be recorded 
by Gartner's tonometer. 

As the uterus contracts the condensed steam is expelled 
through the outflow tube mixed with blood and mucus. 
The application generally lasts from ten to fifteen seconds ; 
in other cases, if atresia is not to be feared or even 
perhaps desirable, it may last as long as two minutes. 

The author always performs a preliminary exploratory 
curetment. Carcinoma of the body of the uterus is 
always a contraindication. The operation is also contra- 
indicated in young individuals, in the presence of inflam- 
mation of the adnexa and of appendicitis with tumor 
formations. 

The woman must stay in bed ten days after the opera- 
tion. During this time the genitalia are washed with disin- 
fecting solutions ; the cavity of the uterus is not disturbed. 
After two or three weeks, or sometimes earlier, the sound is 
introduced to break up any adhesions that may have formed. 

IV. OPERATIONS PERFORMED AFTER DISSECT- 
ING AWAY THE VAULT OF THE VAGINA 
AND ENLARGING THE CERVIX BY OPERA- 
TIVE MEANS. 

The topographic and surgical anatomy of this opera- 
tion is the same as that just described for the last two 
groups. 

i. Division of the Anterior WaH of the Cervix. 

Bloodless dilatation of the cervical canal offers obstacles 
to any subsequent operative procedures in the uterine 



86 ENLARGING THE CERVIX BY OPERATIONS. 

Plate 17. 

Supravaginal Amputation of the Cervix (after Kaltenbach).— Cir- 
cular incision of the vaginal portion beginning in the anterior vault of 
the vagina. The operating field is exposed as for an anterior kolpor- 
rhaphy, the two lips of the os being held with double tenacula. 

Plate 18. 

Supravaginal Amputation of the Cervix (after Kaltenbach).— Liga- 
tion of the uterine artery. The artery is, of course, ligated before the 
neck is excised, not, as shown in the picture for the sake of clearness, 
after excision of the cervix. The ligation is performed opposite the 
supravaginal portion of the cervix, the point being readily recognized by 
the pulsation. 

Plate 19. 

Supravaginal Amputation of the Cervix (after Kaltenbach).— Divi- 
sion of the cervix, which has been dissected out ; the anterior half 
of the wall is divided first. On either side the ligatures of the uterine 
artery are seen. Sutures are then introduced, uniting the border of the 
wound in the cervical mucous membrane with the vaginal wound. [The 
figure represents this as having been carried out anteriorly. — Ed.] 

Plate 20. 

Enucleation of a Polypous Fibromyoma after Division of the Ante- 
rior Wall of the Cervix. — Separation of the anterior wall of the cervix ; 
a catheter or probe is introduced into the urethra so as to avoid any 
injury to the wall of the bladder. A second probe serves as guide for the 
scissors in dividing the inner os. 



cavity similar to those found in operating in the bladder 
after dilatation of the urethra — namely, increased diffi- 
culty of manipulation from the fact that the object to be 
removed has to be carried through the entire length of 
the cervix. Moreover, the internal os varies greatly as 
regards its dilatability, is often enlarged with difficulty, 
and rarely admits a finger. A. Martin first conceived the 
idea of dividing the entire anterior wall of the cervix up 



Tab. 17. 




m 






Tab. 18. 




1 II 



'hold . Ml 



Tab. W. 




Ltlh.An.st A' HeichhoUl . Muiirhcn . 



Tab. 20. 



. 1-J ! \\ I 




LUh. Aral F. Rpjaiiwkl , Miinchen . 



DIVISION OF THE ANTERIOR WALL OF CERVIX. 87 

to and including the internal os. To do this the bladder 
must be dissected away from the cervix after the anterior 
vault of the vagina has been opened by a transverse or 
T-shaped incision. 

The vaginal portion is drawn down into the speculum, 
the anterior lip of the cervix seized with a double tenacu- 
lum and drawn down until the entire anterior vault of 
the vagina comes into view. By means of two hooks or 
double tenacula the folds may be drawn out, and, with 
the aid of a third tenaculum, drawing the columna 
rugarum toward the urethra, the anterior wall of the 
vagina may be stretched out perfectly smooth. This 
surface is crossed by a transverse fold (Fig. 21) corre- 
sponding to the line of attachment of the urinary bladder, 
which consists of firmer tissue than that of the fossa, 
which contains the loose cervicovesical connective tissue. 
In dissecting the bladder away this fold must be avoided. 
The dissection is carried through the looser tissue to the 
level of the internal os extraperitoneally. The serous 
membrane may be detached if necessary. The dissection 
is accomplished by means of a transverse incision between 
the anterior lip of the os and the transverse fold above 
referred to (Plate 17), the loose connective tissue being 
pushed aside with a blunt instrument, as shown in Fig. 15. 

To enlarge the wound, and at the same time to remove 
the bladder beyond the reach of cutting instruments, the 
upper tenaculum is inserted into the upper surface of the 
wound and drawn upward ; or a narrow retractor may be 
used instead of a tenaculum. The wound is then enlarged 
in both directions with a blunt instrument. The dissect- 
ing scissors should always be held close to the dense tissue 



88 ENLARGING THE CERVIX BY OPERATIONS. 

Plate 21. 

Enucleation of a Polypous Fibromyoma after Division of the Ante- 
rior Wall of the Cervix.— Dilatation of the internal os with Fritsch 
metal dilators. 

Plate 22. 

Enucleation of a Polypous Fibromyoma after Division of the Ante- 
rior Wall of the Cervix. — Morcellement of larger polyps and removal 
of small polyps near their base after the latter has been ligated. 

Plate 23. 

Enucleation of a Polypous Fibromyoma after Division of the Ante- 
rior Wall of the Cervix. — Method of closing the cervical wound with 
interrupted catgut sutures tied in the lumen of the cervix (illustration 
of the surgical double knot). 

of the Avail of the cervix. As soon as the latter has been 
completely exposed, it is divided along the median line as 
far as and including the internal os (Plate 20). 

If a preliminary simple dilatation of the cervical canal 
has been performed (Plate 21), this operation enables us 
to palpate the uterine cavity, or proceed to certain other 
operations, such as the removal of foreign bodies (a broken 
uterine catheter or a tent that has accidentally entered 
the uterine cavity) ; the removal of polyps and prominent 
submucous fibromyomata with or without preliminary 
morcellement (Plate 22). The method of performing the 
latter operations is the same as that already described. 

The divided wall of the cervix is afterward closed by 
means of transverse catgut sutures passing through the 
entire wall of the viscus from without inward, and tied 
in the cervical canal (Plate 23). The bladder, which has 
been separated from the cervix, is reattached by means of 
a transverse row of sutures, so that no " dead spaces " are 



LIGATION OF THE UTERINE ARTERY. 89 

left in the depths of the wound. One or two very deep 
or buried sutures, as shown on Plate 20, are usually 
required. The edges of the incision in the mucous mem- 
brane must be brought into accurate apposition and in- 
cluded in the last-mentioned sutures (Plate 28). 

Simple division of the vesicocervical septum and of the 
parametrium is performed as a preliminary measure to the 
following operations : Ligation of the uterine artery, 
supravaginal amputation of the neck of the uterus, 
operations for the cure of vesicocervical and vesico- 
ureterocervical fistulas, and the evacuation of abscesses 
in the parametria. 

2. Ligation of the Uterine Artery. 

This is performed as a preliminary step in total or 
partial extirpation of the uterus ; as an independent 
measure in the presence of profuse bleeding myomata in 
patients who, as the result of Menorrhagia lasting for 
years, have become so reduced in their general condition 
and whose hearts are so weak that they cannot be subjected 
to the risk of a radical operation or even to anesthesia — 
in other words, as a palliative operation. 

It has been shown in the consideration of the anatomy 
that the uterine artery approaches the uterus from above 
and from the side, and at the level of the supravaginal 
portion of the cervix, 2 cm. from the wall, divides into 
its branches ; this point is, therefore, about 3 cm. above 
the external os. The artery at this point intersects the 
ureter so that the latter, which up to that point was 
median and posterior to the artery, now lies behind the 
horizontal portion of the artery and passes forward in 



90 ENLARGING THE CERVIX BY OPERATIONS. 

front of the branch known as the cervicovaginal artery. 
At the same time it approaches to within 1 cm. of the 
wall of the cervix, then converges toward the ureter of 
the opposite side, and enters the posterior wall of the 
bladder after passing through the loose connective tissue 
of the cervico vesical septum. 

It follows from the foregoing description that the 
uterine artery is most accessible when the posterior wall 
of the bladder and the ureters have been detached from 
the cervix as far as possible in a lateral direction — that is 
to say, when the parametria have been actually divided 
into two portions, the anterior of which includes the 
bladder and ureters, while the posterior portion contains 
the neck of the uterus and the uterine vessels. 

Hence there are two methods of effecting the ligation : 
Either the lateral walls of the vaginal vault may be 
opened separately and each ureter pushed away from the 
uterus with the finger, after which three or four ligatures 
are placed about the cervicovaginal artery, about the 
horizontal portion, and finally about the main trunk of 
the uterine artery itself; or access may be obtained by a 
transverse incision in the anterior vault of the vagina, 
which is enlarged as much as possible in a lateral direc- 
tion ; the bladder and both ureters are then pushed back 
as a whole, thus avoiding the dangers of injuring them, 
of passing a ligature about them, or of producing a kink in 
one of them. The steps in the operation are, therefore, 
the same as in that previously described (see p. 87), 
except for the division of the cervix. Instead of the 
latter procedure the pulsating vessels are sought for with 
the palpating finger ; the cervicovaginal branch in the 



LIGATION OF THE UTERINE ARTERY. 



91 



vault of the vagina is usually found and ligated first. 
Then the main trunk or the horizontal portion running to 
the cervix is ligated. Two ligatures should be applied 





Fig. 20. — Enucleation of a polypoid fibromyoma after division of the ante- 
rior wall of the cervix. Closure of the wound in the anterior vault of the 
vagina by button sutures. These are placed from right to left, whereas the 
tied sutures of the vaginal wall run from above below— both in the direction 
of the incisions. While the sutures in the vaginal portion are visible, buried 
sutures are placed in the pars supravaginalis. 



and the vessel divided between them. If the uterus is 
drawn too far downward, or the specula are too tightly 
packed in the vagina, the pulsation ceases to be felt ; 



92 ENLARGING THE CERVIX BY OPERATIONS. 

hence it is important to remember to loosen these instru- 
ments from time to time (compare Plate 18). 

The wound in the vault of the vagina (Plates 20, 
28) is closed in the same way as already described (see 
Fig. 20), the lateral portions of the wound especially 
being held together with deep buried sutures. 

The reports in regard to the result of this palliative 
operation in the presence of bleeding mvomata and in 
greatly debilitated patients are extremely variable, and 
the operation is, therefore, rarely performed. In one 
remarkable case in which the bleeding had lasted ten 
years and the patient had become extremely anemic and 
the heart was very weak, I obtained a brilliant result. 
The operation when performed without anesthesia is, of 
course, extremely painful, owing to the proximity of so 
many ganglia, especially the large cervical ganglion. To 
secure the necessary time to put a patient in good condi- 
tion for a radical operation, the procedure is distinctly to 
be recommended. There is little danger of gangrene, 
owing to the anastomoses of the uterine artery with the 
ovarian artery. 

3. Supravaginal Amputation of the Cervix (Schroder, 
Kaltenbach). 

This operation consists in supravaginal and extraperi- 
toneal amputation of the neck of the uterus below the 
internal os, and is usually performed in strictly circum- 
scribed cancer of the vaginal portion. It is to be em- 
phasized, however, that even in the early stages of a 
tumor, malignant tissue has been found in the body of the 
uterus. If, therefore, the latter is thickened ; if there is a 



SUPRAVAGINAL AMPUTATION OF CERVIX. 93 

history of atypical bleeding, or the tumor in the vaginal 
portion partakes of the nature of an adenocarcinoma, the 
latter operation is to be preferred in every case. The 
concensus of opinion inclines to total extirpation. [Most 
emphatically. — Ed.] Nevertheless it is not to be denied 
that excellent permanent results have been obtained by 
high amputation of the cervix. 

The first step in the operation consists in division of 
the cervicovesical septum (Plate 17). The incision is 
enlarged in a lateral direction, since the cervix lies in the 
distribution of the main branches of the uterine artery, 
which accordingly must be ligated after the method just 
described, before amputation of the cervix is begun. 

The anterior vault of the vagina is drawn out with two 
double tenacula, as shown on Plate 17, and the vaginal 
portion is drawn upward. The two lateral extremities 
of the incision are then united by a curved incision 
around the vaginal portion. The branches of the uterine 
artery are then ligated (Plates 18, 19). The vaginal 
mucous membrane is pushed back, and the cervix is com- 
pletely pulled down so that the edges of the vaginal 
mucous membrane that surrounds the os like a collar give 
the organ the appearance of a mushroom. 

The vaginal portion is drawn downward and the ante- 
rior wall is divided with the knife near the internal os, so 
that the cervical canal is completely laid open and its 
mucous membrane can be secured with catgut sutures, 
which are carried through the outer edges of the wound 
in the vagina (Plate 19). This is then followed by a 
complete amputation of the cervix. The closure of the 
wound is then completed in the manner just described, so 



94 ENLARGING THE CERVIX BY OPERATIONS. 

that eventually the cervical and vaginal mucous mem- 
branes are united by a wreath of sutures similar to those 
shown in Plate 16. The ligatures around the uterine 
artery are buried (Plate 19). 

4. Operation for the Closure of Cervicovesical and Cervico= 
ureteral Fistulas. 

This operation can be performed only when the genital 
opening of the fistula has been made readily accessible 
by simple dilatation of the cervical canal (rarely), or, 
what is usually necessary, by completely laying bare the 
wall of the cervix after dissecting away the bladder, or, 
as has been done in a few cases, after simple division of 
the cervix. 

The second method is the surest, because the fistulous 
canal is divided into two different parts, a vesical and a 
cervical portion, so that each segment can be independ- 
ently cureted and obliterated by bringing surfaces of 
fresh tissue together. When the bladder is dissected 
away, as much loose tissue as possible must be left 
attached to it, so as to give the viscus as much mobility 
as possible. Whether the vesicouterine excavation will 
require to be opened and the anterior uterine wall utilized 
in the plastic operation will depend, in an individual case, 
on the extent of the defect. 

The sutures are introduced in essentially the same way 
as in the case of a vesicovaginal fistula and in closure 
of the wound after division of the vesicocervical septum 
(Plate 12 and Fig. 20). 

The patient must not be allowed to leave her bed for 
two weeks. The after-treatment is the same as that in 



CLOSURE OF CEBVICO VESICAL FISTULA. 



95 



all operations on the vaginal vault. [The bladder should 
be drained several days with a catheter. — Ed.] 

The surest method of closing a ureterovaginal fistula is 
that of Mackenrodt — through the vagina. An artificial 



;*' 




N 



Fig. 21.— Anterior kolpoceliotomy. Showing the fold which is made perma- 
nent when the vaginal portion is drawn forward, and which indicates the line 
of insertion of the bladder. 

vesicovaginal fistula is made, and a vaginal flap, some- 
what larger than the artificial opening, is dissected from 
around the opening of the ureteral fistula ; this flap and 
the opening of the ureter are then utilized to cover in 
the artificial vesicovaginal fistula. 



96 OPENING OF THE VESICO-UTERINE FOSSA. 

Plate 24. 

Anterior Kolpoceliotomy.— Dissecting the bladder away from the 
cervix (anterior kolpotomy). 

If these operations fail and the surgeon does not desire 
to operate by the abdomiDal route, the only possible 
expedients are hysterocleisis or kolpocleisis, or extirpation 
of the corresponding kidney. These procedures, as has 
already been said, are very unsatisfactory. 

5. Method of Opening Abscesses in the Parametria (Pelvic 

Abscess). 

If pus has been obtained by exploratory puncture or 
the temperature-chart indicates a hectic condition and 
appears to indicate absorption of pus, the abscess should 
be incised at the point where fluctuation is made out 
or where the tissues appear most prominent. After the 
abscess cavity has been opened, free drainage is maintained 
by means of a drainage-tube or a loose packing of iodo- 
form gauze. 

V. OPERATIONS THAT REQUIRE OPENING OF 
THE VESICOUTERINE FOSSA. 

The vesico-uterine peritoneal pouch is opened, partly 
to fix the uterus anteriorly and partly as a preparatory 
measure, in operations on the exterior or interior of the 
uterus after it has been delivered through the kolpotomy 
opening, and in operations on the adnexa when the latter 
are not situated too high, at the pelvic inlet or in the 
posterior pouch of Douglas, and are not fixed by peri- 
toneal adhesions that cannot be directlv seen. 



ANTERIOR KOLPOCELIOTOMY. 97 

(For the topographic and surgical anatomy see Groups 
II., in., and IX.) 



i. Anterior Kolpoceliotomy. 

The beginning of the operation is the same as the 
opening of the anterior fornix described in the foregoing 
section. Instead of a transverse incision, a longitudinal 
incision may be made, reaching as far up as the portio 
vaginalis. After the vaginal flaps have been undermined 
and dissected away, the wound is stretched to form a 
rhomboid. Two incisions may also be united in the 
form of a T. The bladder is now pushed back above 
the internal os, which is about three centimeters higher 
than the external os (Fig. 15, Plate 25), the cervico- 
vesical connective tissue being divided with a blunt 
instrument. The incision must be lengthened laterally — 
and this may be accomplished by lateral stretching with 
the fingers. The bladder, after being exposed, is raised 
along with the ureters by means of a retractor. The 
boundary of the bladder is usually marked by a fold 
(Fig. 21); if not, it can be determined by means of the 
catheter. The peritoneal fold of the anterior peritoneal 
pouch must then be reached underneath the bladder. It 
may frequently be recognized by the eye as a bright 
transverse line. The peritoneum should not be separated 
above the internal os. The dissection is carried on in 
the main with a blunt instrument, assisted with a few 
clips of the scissors to divide the firmer fibers, especially 
in the median line. The bladder is the only structure 
that is apt to be injured, and this accident may be avoided 
7 



98 OPENING OF THE VESICO-UTERINE FOSSA. 

Plate 25. 

Fig. 1. — Anterior Kolpoceliotomy. — Exposing the vault of the vagina 
by means of two double tenacula inserted in the vaginal wall. The 
retroflexion of the uterus has been corrected. The point where the an- 
terior pouch of Douglas is opened is indicated in the cervicovesical 
septum. 

Fig. 2. — Vaginifixation of the Uterus after Kolpoceliotomy (Duhrs- 
sen). — Introduction of the suture underneath the fundus of the uterus 
in the fold of the anterior pouch of Douglas. 

Plate 26. 

Ovariotomy Following Anterior Kolpoceliotomy. — The uterus and 
ovary are drawn forward in front of the vulva through the anterior 
kolpotomy wound, after opening of the anterior peritoneal pouch, tbe 
peritoneal fold of which surrounds the organs in the picture. The sub- 
serous vessels in the fundus of the uterus appear engorged on account of 
the strangulation. 

by keeping close to the wall of the cervix, which is 
readily recognized by its greater hardness. 

After a small incision has been made in the peritoneal 
cavity with the scissors, it is to be enlarged with the fingers 
or dressing forceps. The edges of the peritoneal wound 
are temporarily secured with catgut sutures, and the 
lateral retractor, which had been used to raise the bladder, 
is introduced into the opened vesico-uterine fossa. 

2. Vaginifixation (Vaginifixura Vesicofixatio Uteri) (Diihrs- 
sen and Mackenrodt). 

These operations may be performed immediately after 
anterior kolpoceliotomy. 

If the uterus is movable and retroflexed and reposi- 
tion and retention have not been effected by means of a 
pessary, the organ may be secured by some anterior 
operation, such as fixation of the anterior uterine wall to 






Tab/26. 



i 




<\ 



/ 



■ 



.— i~. 



7%& 



"^ 





LUh 



iho/d. Mitnchen. 



VA GIN I FIX A TIOX. 9 9 

a vaginal incision by means of sutures. To obtain the 
greatest amount of fixation the perimetrium should be 
denuded and made to adhere to the true cervicovesical 
septum, because in this way a fibrous union would be 
secured ; but as this operation is apt to interfere with 
labor, it is to be performed only when the woman is 
approaching the climacterium. Another important point 
is to close the peritoneal pouch before the fixation sutures 
are tied, for it has been found by experience that sutures 
introduced through the fundus of the uterus are apt to 
interfere with the development of the anterior wall of 
the organ at the next succeeding pregnancy, resulting 
either in abortion or in mere distention of the posterior 
wall. It also interferes with dilatation of the os, so that 
the anterior wall of the cervix may have to be laid open 
or a Cesarean section performed. 

In performing the operation of fixation in women 
capable of bearing children the following precautions 
must be observed, it being remembered that the fundus 
of the uterus may become firmly fixed below. As a rule, 
therefore, one should advise against the operation in 
women of this class. The Alexander-Adams method 
of shortening the round ligaments or ventrosuspension of 
the uterus is much to be preferred. 

After the vesico-uterine fossa has been opened (Plates 
17, 24, Fig. 21) and the edges of the peritoneal incision 
have been secured with sutures, the uterus is to be drawn 
over forward out of its position of retroversion or retro- 
flexion. This is accomplished by seizing the os with a 
tenaculum and pushing the latter backward — that is, 
toward the curve of the sacrum (Plate 25, Figs. 2, 



100 OPENING OF THE VESICO-UTEBINE FOSSA. 

26). The uterus is thus brought into a vertical position, 
making it possible to seize the anterior wall with a 
double tenaculum. A second tenaculum is then applied 
higher up, near the fundus, and a third above that, and 
so on, each successive tenaculum seizing a higher point 
of the organ until the part to be fixed has been brought 
into view or the body of the uterus can be brought 
through the peritoneal incision into the vagina or in 
front of the vulva (Plates 25, 26). 

The fixation sutures are now introduced either near the 
point of attachment of the round ligaments, which may 
be included, or directly in the wall of the uterus — not at 
the fundus, however, but two or three centimeters above 
the internal os ; the sutures are carried through the peri- 
toneum near the incision, and emerge on the vesical sur- 
face (Plate 25, Fig. 2). Before these sutures are drawn 
tight, all the sutures passing from serous membrane to 
serous membrane required to close the wound in the 
peritoneal fold must be put in place, or the wound in the 
peritoneal fold may be closed first, after two silkworm- 
gut sutures have been introduced in the wall of the 
uterus and their free ends brought out through the 
vagina. If the latter are tied after the vaginal wound 
has been closed in the manner already described, the 
fundus of the uterus will be brought in close contact 
with the floor of the vesico-uterine fossa ; and adhesions 
will form at this point with the anterior wall of the 
uterus. The silkworm-gut sutures are removed later. 
Convalescence requires two weeks. 

[It cannot be too strongly urged that uterine fixation 



OPERATIONS ON THE UTERUS. 101 

should never be performed in women who are likely to 
become pregnant. — Ed.] 

3. Operations that can be Performed on the Uterus with 
the Aid of Anterior Kolpoceliotomy. 

These operations include removal of subserous fibro- 
myomata or of early interstitial or cornual pregnancies. 

Subserous fibromyomata are either pedunculated, like 
polyps, or they represent prominent tumors with a broad 
base which is embedded in the wall of the uterus. In 
the former case the pedicle is ligated and a suture intro- 
duced under its base for the purpose of drawing the 
tumor or the neck of the uterus down into the vagina. 
In the other case the tumor must be enucleated from its 
foundation, a procedure which can be performed without 
much trouble. The exception is formed by adenomyo- 
mata situated near the tubes, which, in accordance with 
their mode of origin, are closely adherent to the sur- 
rounding tissues. In the latter case the tumor is ligated 
in sections unless the uterus is to be completely extir- 
pated. In both cases the entire bed of the tumor, in- 
cluding the deeper layers, must be closed and accurately 
covered with peritoneum. If the base of the tumor 
extends as far as the endometrium, or if the uterine 
cavity is opened during its removal, the mucous mem- 
brane and contiguous muscular layers must be united 
separately and the sutures tied in the uterine cavity. If 
it is desired to avoid having the sutures project into the 
cavity, — although with a healthy mucous membrane the 
procedure is perfectly safe, — buried sutures are introduced 
so that they just catch the edge of the endometrium, very 



102 OPENING OF THE VESICO-UTERINE FOSSA. 

Plate 27. 

Ovariotomy after Anterior Kolpoceliotomy.— Application of the 
ligatures to tie off the ovaries and tubes. One of the ligatures includes 
the utero-ovarian ligament and the uterine insertion of the tube ; the 
other is passed over the latter and the suspensory ligament of the ovary, 
or infundibulopelvic ligament. 

Plate 28. 

Ovariotomy after Anterior Kolpoceliotomy. — Continuous suture to 
close the peritoneal and vaginal wounds (compare Plate 9). 

much as in the case of a vesicovaginal fistula (Plate 12). 
It goes without saying that only small fibromyomata, 
smaller than an apple in size, should be removed by this 
method. 

The removal of a gravid accessory cornu in the case of 
a bicornute uterus, or of an interstitial pregnancy, condi- 
tions in which rupture is apt to take place into the peri- 
toneal cavity, cannot be described as typical procedures. 
The former resembles in its technic the operations on the 
adnexa, especially the removal of a tubal sac ; the latter 
belongs rather to enucleation of myomata. Such patho- 
logic structures usually require a celiotomy for their 
removal. 

4. Operations on the Adnexa. 

The question whether an operation on the adnexa can 
be performed by anterior kolpoceliotomy depends not so 
much on the size of the tumor, since the contents are 
usually fluid and can be removed by a previous incision, 
as on its seat — viz., whether it is fixed at the pelvic inlet 
or in the posterior pouch of Douglas ; whether there are 
numerous vascular adhesions with knuckles of intestine 



Tab. 2 7. 




Ltih . Anst E ReCchhoLd. Munch* 




' 







I 





Jfe 

I 



OPERATIONS ON THE ADNEXA. 103 

or with the omentum, which are difficult to reach ; or 
whether there are other extensive adhesions with the 
peritoneum. The field of usefulness of anterior kolpo- 
celiotomy, therefore, includes large tumors that are 
readily evacuated, or smaller, hard growths, freely mov- 
able and situated below the pelvic inlet in the anterior 
pouch of Douglas or on the posterior surface of the 
uterus if the latter is normally placed. It does not in- 
clude tumors adherent in the posterior pouch of Douglas. 
The list of pathologic conditions embraces ovaries (cas- 
tration), parovarian and ovarian cysts, cystoma, dermoid 
cysts, small ovarian fibromata, and the like ; tubal gesta- 
tion in the first months ; hydrosalpinx and pyosalpinx, 
when not situated too high and not bound down by toe 
many adhesions ; and, possibly, tumors of the appendix. 

The removal of ovarian tumors and the like is re- 
garded as a typical operation consisting chiefly in liga- 
tion of structures more or less distinctly pedunculated. 
Another typical operation is " sterilization " (castration) 
by excision of the tubes from the horns of the uterus, 
followed by double ligation of the former. 

After the tumor, the ovary, or the uterus and its ovi- 
ducts have been exposed as in the method described in 
connection with vaginal fixation (Plate 26), the arteries 
are ligated and the entire base of the part to be removed 
is tied off. The most important vessels are the ovarian, 
which reach the adnexa by way of the suspensory liga- 
ment of the ovary (infundibulopelvic ligament), and the 
tubal and ovarian branches, which pass upward from the 
uterine artery. Ligation of the sharp-edged suspensory 
ligament, of the insertion of the tube in the uterus, and 



104 OPERATIONS THROUGH POUCH OF DOUGLAS. 

of the utero-ovarian ligament (Plate 27), suffices to cut 
the adnexa completely off from the portion of the circu- 
lation by which they are supplied. Partly to guard 
against possible secondary hemorrhage, or to control it 
more readily if the accident occurs, and partly to fix the 
uterus anteriorly, it is well to attach the stump in the 
corresponding side of the vaginal wound by means of 
sutures, as shown in a semidiagrammatic way on Plate 
33. The kolpotomy wound is closed by means of inter- 
rupted or continuous catgut sutures (Plate 28) ; in in- 
fectious cases, however, the wound must be drained. 

Intraligamentary subserous cysts and those situated in 
the posterior wall of the pouch of Douglas require a 
special technic for their enucleation. They cannot be 
removed by means of kolpoceliotomy unless they are 
quite small. Pelvic abscesses, owing to the great ten- 
dency of pus-tubes to become adherent in the posterior 
pouch of Douglas, are usually attacked through the 
posterior wall of the vagina. 

The possibility of error in the diagnosis is always to 
be kept in mind, and preparations should be made for a 
possible celiotomy or total extirpation. 

In cystadenomata, even when they are benign, the 
danger of metastasis is greater with kolpoceliotomy than 
with celiotomy. 

VI. OPERATIONS THAT ARE PERFORMED 
THROUGH THE POSTERIOR POUCH OF DOUGLAS. 

It follows from the topographic description under 
Groups II., III., and IV., that the distance to the recto- 
uterovaginal fossa is much shorter posteriorly than ante- 



KOLPOCELIOTOMY AND BE 'TRO FIXATION. 105 

riorly. The actual distance, however, to the normally 
situated ovary is greater by the posterior route than by 
the anterior ; hence the peritoneal cavity should be 
entered posteriorly only for operations on masses situated 
in the posterior peritoneal pouch itself, or associated with 
a retroflexed uterus. The conditions that may be attacked 
in this way are, therefore, ovarian and parovarian tumors, 
intraligamentary or retroperitoneal tumors, tubal preg- 
nancies, pus-tubes, pelvoperitoneal incapsulated abscesses, 
retro-uterine hematocele, tumors of the uterus, and adhe- 
sions in the posterior pouch of Douglas ; also, in cases of 
infantile scanty development with a tendency to entero- 
cele in which the pouch of Douglas is to be obliterated, 
with or without retrofixation of the cervix. 

If a tumor in the pouch of Douglas is closely related 
to the rectum and the entire mass has prolapsed into the 
lumen of the vagina, removal is often effected most easily 
through a rectal incision in the rectocele thus produced. 
[Such a procedure as this would not be considered as 
justifiable by most authorities, unless removal were found 
to be impossible by the vaginal or abdominal routes. — 
Ed.] 

i. Posterior Kolpoceliotomy and Retrofixation of the 
Cervix. 

The posterior vault of the vagina is brought into view 
by drawing the posterior lip of the os upward and insert- 
ing two hooks in the lateral folds of the posterior vault of 
the vagina, the perineum and posterior vaginal wall being 
at the same time depressed with a spatular speculum. After 
the posterior vaginal fornix has been incised (Plate 3), the 



106 OPERATIONS THROUGH POUCH OF DOUGLAS. 

rectum, along with the entire peritoneal pouch, is separated 
for a short distance from the cervix with a blunt instru- 
ment. The pouch is readily recognized with the finger 
by the gliding of one smooth surface over another. The 
vaginal surface is picked up with forceps and snipped 
with the scissors. The incision is then enlarged by dila- 
tation (Plate 4). The edge of the peritoneum is fixed 
with sutures. If the hemorrhage is profuse, several 
fixation sutures are introduced, as above, in the vaginal 
mucous membrane. According to Lohlein, the mere act 
of opening the retro-uterine fossa has a curative effect in 
pel voperitoneal tuberculosis. 

Retrofixation of the cervix and obliteration of the peri- 
toneal pouch are effected by means of several intraperi- 
toneal catgut sutures introduced between the posterior 
wall of the cervix and the parietal investment of the 
sacrum and rectum (Plate 5). The edge of the peri- 
toneal wound is closed with catgut, an interrupted, a 
continuous, or even a tobacco-pouch suture being used 
(Plate 6). The vaginal vault is closed by means of deep 
buried sutures (Plate 7). This operation may be imme- 
diately followed by a posterior kolporrhaphy, described 
elsewhere (Plate 8, Fig. 13), it being remembered that 
the vaginal vault itself is not to be narrow T ed. Conva- 
lescence lasts two weeks. 

2. Operative Treatment of Ectopic Gestation and its 
Consequences. 

The tubal sac containing the young ovum is readily 
ligated and removed, especially when it is fixed only by 
soft adhesions. If the sac is ruptured or a tubal abortion 



THE OPERATIVE TREATMENT OF ABSCESSES. 107 

has taken place, the pelvic cavity will be filled with fresh 
or freshly clotted blood ; in some cases the tube itself is 
found to be bleeding. If the hemorrhage has taken 
place some time before, the retro-uterine fossa is found 
filled with a mass of thickly clotted blood and blood 
intermingled with layers of fibrin. This retro-uterine 
hematocele offers no protection against secondary hemor- 
rhage, as the cells of the chorion which remain are 
capable of eating through the wall of the tube. It is, 
therefore, quite justifiable to turn out the clot and ligate 
the tube. The ligation, however, is not necessary if the 
tube is free and uninjured and no enlargements are felt 
anywhere. [This section must be regarded as a very 
scanty and inexact account of the operative treatment of 
ectopic gestation. — Ed.] 

3. The Operative Treatment of Abscesses in the Pouch of 
Douglas. 

Simple inflammatory adhesions between the uterus and 
its adnexa may be divided with a blunt instrument [or 
finger. — Ed.]. If the adhesions are vascular, they should 
be tied with two ligatures and the intervening tissues 
divided. Pus-tubes that are not adherent or only slightly 
adherent should be excised from the corresponding horn 
of the uterus ; but the prospect of a permanent cure is 
doubtful. Sometimes an inflamed appendix occupies the 
pouch of Douglas and may be removed directly from that 
situation. [Not a satisfactory procedure. — Ed.] In 
some cases the entire peritoneal space corresponding to 
the pouch of Douglas and the pelvis is filled with adhe- 
sions and intervening multiple abscesses, the original 



108 OPERATIONS THROUGH POUCH OF DOUGLAS. 

tissue having been entirely destroyed. In such a ease it 
is, of course, quite out of the question to open the 
posterior peritoneal pouch, nor should the scissors or 
knife be used, on account of the danger of injuring loops 
of intestine which may have become caught in the adhe- 
sions. The collections of pus must be evacuated one 
after another, the tissues being dissected away with a 
blunt instrument. Complete extirpation of the uterus 
and adnexa is the best treatment for such a condition. 

Sometimes abscesses of this kind have already evacuated 
their contents into the rectum ; but partly because the 
evacuation has been incomplete, and partly because of 
the reinfection that usually takes place on account of the 
rigidity of the pus-cavity which enables it to aspirate 
material from the rectum, the suppuration continues. 
Free drainage must then be provided by laying the 
abscess wide open from the vagina. If the abscess is 
situated higher up, it must be secured to the wall of the 
vagina by means of sutures. Under these circumstances 
there is also the danger of the passage of feces into the 
vagina — that is, of the formation of a high rectovaginal 
or ileojejunovaginal fistula. The author has, however, 
seen several of these fistula? cured by the introduction of 
strips of gauze saturated in oil of turpentine as soon as 
suppuration had ceased. In other favorable cases a 
minute fistula remains and gives rise to no symptoms. 
In all cases of this kind the pouch of Douglas should be 
packed with iodoform gauze. 



OPERATIONS BY OPENING PERITONEA L POUCHES. 109 

VII. OPERATIONS PERFORMED AFTER OPENING 
ONE OR BOTH PERITONEAL POUCHES AND 
AN ENTIRE WALL OF THE UTERUS. 

This combination of procedures, which has as its object 
the preservation of an organ so as to be capable of partu- 
rition, may be indicated for the simultaneous enucleation 
of multiple subserous, intramural, or submucous fibromyo- 
mata, and for the purpose of bringing about a reinversion 
of an inverted uterus. 

In the case of tumors, a longitudinal incision through 
the wall of the body or of the entire uterus enables the 
operator not only to remove single deeply situated tumors, 
but also to determine the presence of smaller tumors by 
direct palpation and inspection, and this, according to 
A. Martin, is of the greatest importance to guard against 
the occurrence of the so-called relapses. 

In regard to reinversion, it may be performed, accord- 
ing to Kiistner, through the posterior wall of the vagina. 
The vault and the posterior wall of the body of the 
uterus alone are incised. The divided wall is invaginated 
toward the perimetrium, which forms a pocket, and at the 
same time the latter is drawn out by means of a curved 
dressing forceps from the posterior pouch of Douglas. 

Failure to effect reinversion in this way is due to 
insufficient length of the incision. In such a case it is 
better to divide the entire wall, including the neck and 
vaginal portion (^Vestermark-Borelius), and not to invag- 
inate the uterus toward the perimetrium, but, on the 
contrary, to widen the incision so that the fundus may be 
pushed into the pouch of Douglas. The posterior wall of 



110 OPERATIONS BY OPENING PERITONEAL POUCHES. 

Plate 29. 

Total Extirpation of the Uterus through the Vagina (Czerny).— A 

ligature is tied around the suspensory ligament of the ovary (the infun- 
dibulopelvic ligament), and a second ligature applied around the broad 
ligament, which should reach as far as the round ligament. The uterus 
has been turned through the anterior kolpotomy wound, bringing the 
portion separated from the bladder into view. 

Plate 30. 

Total Extirpation of the Uterus through the Vagina.— Ligation of 
tissues down to the vaginal vault. This ligature is in immediate contact 
with the last-mentioned ligature, and ties off the uterine arterv. 



Plate 31. 

Total Extirpation of the Uterus through the Vagina. — Method of 
separating the uterus, also the left broad ligament, after all the ligatures 
in that ligament have been tied. The organ is in extreme anteflexion. 

Plate 32. 

Total Extirpation of the Uterus through the Vagina (Czerny).— 
Opening of the posterior pouch of Douglas. This is followed by opening 
of the anterior pouch, after which the bladder and both ureters are dis- 
sected out. The vaginal portion is drawn forward and upward. The 
cervix is separated from the posterior pouch of Douglas and from the 
rectum by a transverse incision, and, if necessary, by an additional 
median longitudinal incision. The peritoneal cavity is then opened. The 
field of operation is exposed by means of four double tenacula, the lowest 
of which may be replaced by a grooved speculum. 

the uterus is now closed by means of transverse inter- 
rupted sutures of catgut, and the posterior wall of the 
vagina is finally closed secundum artem. Sometimes the 
same operation is more readily performed through the 
anterior vault (Kehrer), but Kustner's method is adopted 
probably because in these cases retroflexion is more com- 
mon than anteroflexion. 



Tab. 30. 







-ZttfL Anst. F. Reidihold, Munclien. 



Tab. 32. 




TOTAL EXTIRPATION OF THE UTERUS. Ill 



VIII. TOTAL EXTIRPATION OF THE UTERUS 
THROUGH THE VAGINA BY OPENING THE 
ANTERIOR AND POSTERIOR PERITONEAL 
POUCHES. 

(For the topographic and surgical anatomy see Groups II., III., and IX.) 

After the recto-uterine fossa has been opened after the 
manner described in Group VII., Plates 3, 4, 32, and 
the raw surfaces, which in carcinoma usually bleed freely, 
have been temporarily closed with serosomucous sutures, 
the vaginal portion is drawn down (Plate 25). In carci- 
noma the os should be closed with two or three strong 
silk sutures which also serve as retractors, after all the 
external tumor tissue has been removed with the Paquelin 
cautery. The anterior peritoneal pouch is then opened 
(Fig. 15, Plates 17, 24), and the edges of the wound 
closed with sutures. The anterior and the posterior 
incisions should meet at an acute angle as far out as 
possible, so as to enable the operator to push away the 
bladder and ureters and to clear away as much as possible 
of the tissue surrounding the uterus. 

If the vagina is narrow and the uterus large, or if 
there is much tissue to be removed from the sides of the 
organ, access is obtained to the vault of the vagina by 
separating the posterior wall of the vagina with the 
rectum from the vault and from the labia. The hidden 
field of operation can then be brought into view and 
made accessible to the hand by means of two deep 
Diihrssen's incisions extending to the posterior vault of 
the vagina on both sides. Schuchardt first employed 



112 TOTAL EXTIRPATION OF THE UTERUS. 

Plate 33. 

Total Extirpation of the Uterus through the Vagina.— Method of 
closing the vaginal vault. The two stumps are sewed fast in the angles 
of the vaginal wound, where the ligatures about the uterine artery may- 
be seen. 

these incisions for this purpose, and united them in the 
posterior vault by a transverse incision. 

The uterus is now seen hanging in situ, held along its 
entire length by the two broad ligaments. To make it 
still more movable, the base of the broad ligament must 
be divided on each side. But this tissue contains the 
principal branches of the uterine artery ; the latter must, 
therefore, be ligated, the finger being introduced into the 
posterior pouch of Douglas for the purpose of palpating 
the connective tissue and guiding the needle, which is 
inserted at the anterior peritoneal pouch and passed 
around and through the entire base of each broad liga- 
ment (see Plate 18). 

The uterus is now tipped over; that is to say, the 
vaginal portion is forced back into the hollow of the 
sacrum and the body is drawn down into the opening in 
the vault of the vagina with the aid of a double tenaculum 
(Plates 25, 26, 29). The fundus is drawn through the 
opening by the method described under vaginofixation ; 
if this, however, is found impossible on account of the 
swelling of the organ, the uterus must be divided length- 
wise in the median line (P. Midler). [Division of a car- 
cinomatous uterus is a very unwise procedure, owing to 
the risk of transplanting cancer cells. — Ed.] 

The next step is ligation of the broad ligaments, which 
are tied off in several sections. According to Werth's 



Tab. 33. 




$m 



LWi.Anst F. Hetckhold. Miirtrhen . 



TOTAL EXTIRPATION OF THE UTERUS. 113 

recent suggestion, the ovaries should be left behind in all 
cases in which disease of these organs can be excluded. 
If the ovaries are to be removed, the first ligature should 
include the ovarian vessels running in the infundibulo- 
pelvic ligament ; the second ligature is applied to the 
round ligament immediately afterward (Plate 29) ; the 
third includes the remainder of the broad ligament, con- 
taining the main branches of the uterine artery, and 
takes in all the tissues as far down as the vagina 
(Plate 30). 

After the vessels of one side have been taken care of 
in this way, the uterus may be carefully separated from 
the broad ligament on one side by cutting between the 
ligatures and the wall of the uterus with the scissors in a 
line extending from the suspensory ligament of the ovary 
to the vault of the vagina (Plate 31). The same is then 
done on the other side. In dividing the last strands of 
tissue in the lateral portions of the vagina great care is 
necessary because the uterine artery at this point is apt to 
slip from the ligature, or the cervicovaginal branch may 
not have been included in the ligature, so that a severe 
hemorrhage suddenly occurs. If a ligature is then 
hurriedly introduced, or the artery is seized with the 
forceps along with the surrounding tissue, constrictions or 
other injuries of the ureters may easily be produced. 

The sutures and ligatures that have been introduced 
into the adnexa are to be secured in the two lateral 
angles of the wound, as described elsewhere in connec- 
tion with anterior kolpoceliotomy. The wound may be 
entirely closed (Plate 28), or, as in putrefying carcinoma, 
may be drained with iodoform gauze and allowed to 



114 OPERATIONS ON THE GENITAL ORGANS. 

granulate. It strengthens the newly formed floor of the 
pelvis to suture the stumps of the broad ligaments to it. 

IX. OPERATIONS ON THE GENITAL ORGANS 
THAT REQUIRE A CELIOTOMY. 

Topography and Surgical Anatomy of that Portion of the 
Genital Organs Extending into the Peritoneal Cavity. 

If an incision is made in the median line, between the 
umbilicus and the symphysis, it will pass through the 
panniculus adiposus and the loose-meshed tissue of the 
superficial abdominal fascia, which, in the lower abdom- 
inal region, is made up of several layers and gradually 
fades away into the fatty tissue. Beneath this the strong 
aponeurosis of the external oblique comes into view, 
blending with the aponeurosis of the other side in the 
linea alba. This aponeurosis invests the recti muscles 
and the subjacent aponeurosis of the internal oblique, 
while the latter is connected with the aponeurosis of the 
transversalis, which occupies a still deeper level. These 
fasciae all unite in the median line and form the linea 
alba. Immediately below the navel and a little higher 
up the recti muscles are covered only by the aponeurosis 
of the external oblique and an outer layer of the aponeu- 
rosis of the internal oblique, which undergoes division at 
this point ; a posterior layer assists the aponeurosis of the 
transversalis muscle to cover the inner surface of the 
rectus. 

Underneath these fascise, or underneath the linea alba 
and united to that structure, is the transversalis fascia, 
which is covered with serous membrane on the side pre- 



TOPOGRAPHY AND SURGICAL ANATOMY. 115 

senting toward the peritoneal cavity. In the lower 
abdominal region this serous membrane forms the sole 
covering of the recti muscles on their posterior surface. 
The bladder may come into immediate contact with the 
abdominal walls if it is greatly overfilled. The empty 
bladder lies behind the symphysis, and only the middle 
umbilical ligament comes in contact with the linea alba in 
the median line. The cavum prcevesicale superius, filled 
with fatty tissue (see Atlas of Obstetrical Diagnosis and 
Treatment, Plate 58, Fig. 18), extends as far as the upper 
border of the symphysis. 

The linea alba and the supraimposed fatty tissue are 
poorly supplied with blood-vessels. On the deep sur- 
face of the recti muscles, between them and the trans- 
versalis fascia, the epigastric vessels come up from below 
behind the inguinal canal and form a fold, — the plica 
epigastrica, — passing in toward the recti muscles and 
finally upward. In the Trendelenburg position the in- 
testines gravitate toward the diaphragm, and a view of 
the pelvic organs from above is afforded. The bladder, 
if empty, comes into view ; it is supported by the three 
umbilical ligaments and the peritoneal plicce vesicales 
transversa?, which, for a certain distance, run parallel to 
the round ligaments. Its anterior surface shows a deep 
cup-shaped depression, due to the pressure of the nor- 
mally anteflexed uterus (impresio uterina). 

The prevesical space merges on the side into the peri- 
vesical and peri-uterine spaces. The vesical fascia runs in 
one direction from the upper border of the symphysis 
upward and in the other backward toward the inner ori- 
fice of the urethra. It separates the prevesical space 



116 OPERATIONS ON THE GENITAL ORGANS. 

from the subperitoneal fatty tissue which surrounds the 
bladder-wall. The subperitoneal fatty tissue again merges 
with that of the broad ligaments, from which it is sepa- 
rated only by the visceral fascia of the pelvis. (See Atlas 
of Obstetrical Diagnosis and Treatment, Plate 17, Fig. 29.) 

A knowledge of the relations of these various spaces 
is important not only for the technic, but also to enable 
one to understand the course of an inflammatory proc- 
ess in the connective tissue, as, for instance, the exten- 
sion of parametritis. 

Between the posterior surface of the bladder and the 
anterior surface of the uterus is the vesico -uterine {peri- 
toneal) fossa. This is bounded on the side by the broad 
ligaments with the uterine insertions of the tubes. Be- 
low this peritoneal fold (plica peritonealis), which is 
found at the level of the internal os, the posterior wall 
of the bladder (fundus vesica?) and the cervix are united 
with connective tissue, which, as the vagina is ap- 
proached, becomes looser . in texture and adherent at the 
orifice of the ureters, as has already been described. At 
this point the inferior vesical arteries and branches of 
the cervicovaginal arteries enter the wall of the bladder, 
while the veins pass to the posterior and lateral utero- 
vaginal and vesicovaginal plexuses, as described else- 
where. 

The broad ligaments now leave the bladder and pass 
backward. The position of the uterine body approaches 
the horizontal or the vertical, according to the amount 
of urine in the bladder. The lateral and posterior por- 
tions of the broad ligaments, with the ovaries attached 
to their posterior surfaces, have, under ordinary circum- 



TOPOGRAPHY AND SURGICAL ANATOMY. 117 

stances, a more or less definite relation to the bony pelvis. 
The position of the tube, especially of the freely 
movable fimbriated extremity, depends on the posi- 
tion of the ovary, which is embedded in the ovarian 
fossa ; that is to say, it lies in the posterior portion of the 
obturator fossa, which is bounded above and in front by 
the iliac vessels or the umbilical artery ; behind, by the 
ureter ; and below and in front, by the round ligament 
of the uterus. The position of the ovary is such 
that it comes into relation behind with the ureter and the 
uterine artery and the obturator internus muscle ; above 
and in front with the umbilical artery ; it is roofed over 
both by the pelvic inlet and by the tube, so that it can- 
not be seen at once when the abdomen is opened. 

If a sagittal plane is drawn through the pelvis from a 
point midway between the superior spine of the ilium 
and the symphysis, and this is intersected by a frontal 
plane passing through the middle of the crest of the 
ilium or through the promontory, the point of intersec- 
tion will give the position of the ovary as projected on 
the abdominal wall. 

After repeated pregnancies or conditions attended with 
swelling the ovary is apt to prolapse from the ovarian 
fossa into the hypogastric fossa or into the posterior 
pouch of Douglas. 

The ovary is attached along its lateral surfaces by 
means of the " mesovarium " and the posterior surface 
of the broad ligament. It is roofed over by the am- 
pullar)' portion of the tube, the distal portion of which, 
known as the u descending limb," together with the 
fimbriae of the infundibulum of the tube, hangs free by 



118 OPERATIONS ON THE GENITAL ORGANS. 

the " mesosalpinx " and projects over the inner and pos- 
terior surfaces of the ovary. The mesosalpinx contains 
numerous venous plexuses, as well as the rudimentary 
structures known as the epoophoron and paroophoron, 
which possess a great tendency to undergo cystic de- 
generation. The ovaries are not visible at once when 
the abdomen is opened. The middle portion of the tubes, 
along with the ovary, is attached to the lateral wall of 
the pelvis by means of the infundibulopelvic or suspen- 
sory ligament of the ovary ; this structure conveys the 
internal spermatic vessels to the tube and to the ovary. 
The ovary and the fimbriated extremity of the tube are 
in the immediate neighborhood of the ureter, a relation 
that must be kept in mind both during operations and in 
judging of the extension of a perioophorosalpingitis. 

The tubes and ovaries also come in contact with the 
intestines. The loops of the small intestine which 
hang from the root of the mesentery dip down and may 
completely cover them. On the right side complications 
occur on account of the immediate vicinity of the cecum 
and vermiform appendix to the adnexa. The appendix 
may descend as far as the recto-uterine (peritoneal) 
fossa. 

While the uterus is supported along its lateral mar- 
gins by the broad ligaments as by a pair of wings, the 
anterior and posterior surfaces, as well as the fundus, are 
completely free. Like the broad ligament, these parts 
are covered on the side toward the peritoneal cavity by 
serous membrane, — the perimetrium, — which is closely 
united to the muscular wall of the uterus by a thin layer 
of subserous tissue. Between this area of firm union 



TOPOGRAPHY AND SURGICAL ANATOMY. 119 

and the cervix, where the connection is much looser, 
there is a transitional zone covered by thin but loose- 
meshed, subserous tissue which can readily be dissected 
away. The boundary of the firm union is formed by a 
crescentic line, with the concavity presenting downward, 
and terminating with its two points, behind, in the 
utero-ovarian ligament, and in front, in the round liga- 
ment. The perimetrium merges in front with the peri- 
toneal investment of the bladder ; behind, with that of 
the rectum and parietal peritoneum of the sacrum. The 
edges of the uterus, which are embedded in the broad 
ligaments, are connected with the wall of the sacrum by 
the two recto-uterine folds, which arch backward around 
the recto-uterine fossa and the rectum. They divide the 
posterior pouch of Douglas into an upper, wide portion, 
the "atrium/' and a deeper narrow portion, the "fundus." 
The two folds convey the sacrorecto-iiterine ligaments, 
which contain smooth muscle-fibers (Luschka's muscle) 
and merge one into the other on the posterior wall of the 
cervix, forming a transverse fold, the " torus uterinus." 
(See Atlas of Obstetrical Diagnosis and Treatment, Plate 
17, Fig. 29.) The fundus of Douglas's pouch corresponds 
to Kohlrausch's transverse fold of the rectal mucosa, on 
the one hand, and to the posterior vault of the vagina, on 
the other; it lies 5 or 6 cm. above the anus, and meas- 
ures from 3 to 5 cm. in depth. Normally, intestines are 
found only in the atrium ; if the " fundus " descends, or 
if its depth is greater and it contains loops of intestine, 
there exists an infantile arrest of development which 
may result in the formation of an enterocele or a perineal 
hernia, or, by constriction, lead to the formation of cysts. 



120 OPERATIONS ON THE GENITAL ORGANS. 

Cysts of this kind originate in " peritoneal diverticula." 
On both sides of the rectum two peritoneal pouches ex- 
tend backward, known as the recessus or sacci pararec- 
tales ; they lodge the ovaries and tubes. 

The abdominal cavity must be opened* to permit the 
following operations: extirpation of fibromata, fibro- 
myomata, sarcomata, carcinomata, and other solid tumors 
or tumors filled with a viscous fluid, whether of the 
uterus or of the ovaries, if they are larger than the fist ; 
the extirpation of smaller tumors fixed within or above 
the pelvic inlet, especially tumors of an inflammatory 
nature, such as pyosalpinx, ovarian abscesses, adhesions 
with an inflamed appendix, the masses caused by extra- 
uterine pregnancy ; ventrofixation of an adherent retro- 
flexed uterus after the adhesions have been removed ; the 
removal of fully matured or almost fully matured mace- 
rated fetuses in retention of the ovum, when the uterus is 
high up and it is impossible to dilate the cervical canal, 
especially if there is fever ; the removal of fetuses that 
have escaped into the peritoneal cavity through a complete 
rupture of the uterus ; the Porro operation for a condition 
of this kind ; and, finally, the purely obstetric delivery 
of the child through a Cesarean section on account of 
absolute or relative impossibility to extract it per vlas 
naturales. The incision is usually made in the median 
line, along the linea alba; in rare cases the transverse 
incision in the suprapubic region, advised by Kustner and 
Pfannenstiel, or in certain cases an oblique incision in the 
hypogastric-inguinal region, is employed. 



TRANSVERSE INCISION IN SUPRAPUBIC REGION. 121 

I. The Oblique Incision in the Hypogastric=inguinal Region. 

This is used mostly in perityphlitis, for the evacuation 
of parametritic abscesses, and in a prolonged form in 
injuries of the ureter that cannot be reached through the 
vagina. The abdomen is opened, the posterior parietal 
layer of the peritoneum is incised, and the ureter with its 
sheath dissected out from between the layers of the peri- 
toneum along the ileum as far as the bladder, where 
implantation is performed. The first peritoneal incision 
is closed, and a gauze drain passed down to the site of 
implantation. 

2. The Transverse Incision in the Suprapubic Region. 

The incision is extraperitoneal. It is used for the 
following operations on the bladder : fixation of the 
bladder above, in high degrees of cystocele which cannot 
be permanently fixed through the vagina, according to the 
method described in Group II. : the removal of large 
vesical calculi which cannot be removed either through 
the dilated urethra or with the aid of kolpocystotomy ; 
the extirpation of large tumors of the bladder that cannot 
be subjected to cystoscopic treatment, and the treatment 
of tuberculosis of the bladder by packing the organ with 
iodoform gauze from above. 

The transverse incision in the suprapubic region may 
be extended into the peritoneum after the insertions of the 
recti muscles have been severed and the bladder pro- 
tected. The original transverse incision in such a case 
must be enlarged lengthwise; by this means a number of 
operations otherwise requiring an incision in the median 
line of the abdomen can be performed without danger of 



122 OPERATIONS ON THE GENITAL ORGANS. 

the formation of hernia, which does not occur after a 
transverse incision. In closing the incision the tissues 
are united in separate layers with catgut ; the ends of the 
muscles may, in addition, be advantageously secured with 
deep silver wires or silkworm-gut sutures passing through 
the skin. 

3. Celiotomy with an Ordinary Median Incision through 
the Abdominal Wall. 

An incision in the skin is carried first as far down 
as the fascia ; nothing is gained by making the incision 
through one of the recti muscles either to hasten the 
healing of the wound or to avoid the subsequent produc- 
tion of a hernia. [This is not my practice. I open the 
sheath of each rectus so that the muscles may be closely 
approximated in closing the abdomen. I believe this 
method gives the best result. — Ed.] The abdomen 
should be disinfected the day before and covered with a 
wet bichlorid dressing. Immediately before the operation 
the surface of the abdomen is again cleansed with warm 
soap and water, then with tincture of soap, and finally 
with a solution of bichlorid. The skin must be well 
scrubbed with a brush. 

The peritoneum, as it bulges through the wound, is 
seized with forceps and opened with the aid of a grooved 
director or a finger inserted to protect the intestines, 
which are not infrequently found in immediate contact 
with the peritoneum. If adhesions are found between 
the peritoneum and a tumor, they must be broken up with 
a blunt instrument. If the adhesions are extensive and 
the tissues are firmly united, the question of removing the 



CELIOTOMY WITH ORDINARY MEDIAN INCISION. 123 

entire serous surface may have to be considered. The 
defect thus produced must later be repaired by means of 
a plastic operation. 

If the intestines escape from the cavity during the 
operation, they must be carefully protected against pres- 
sure and sudden cooling ; they are, therefore, covered with 
sterilized cloths or pieces of gauze [soaked in hot normal 
saline solution. — Ed.]. Certain other precautions are 
necessary : fluids contained in a tumor or pus from an 
abscess must be caught in a basin or wiped up [care being 
taken that the general peritoneal cavity is walled off by 
gauze pads. — Ed.] ; all bleeding vessels must be ligated, 
as blood in the peritoneal cavity forms the best medium 
for the development of bacteria which may have effected 
an entrance during the operation. 

To afford a good view of the pelvis, the woman is 
placed in the Trendelenburg position, w T hich causes the 
intestines to gravitate toward the diaphragm. Incident- 
ally it enables the patient to take the anesthetic more 
satisfactorily. While the abdominal wound is being 
closed, however, the patient must be placed in the hori- 
zontal position, because adhesions and ileus are less apt 
to form in this position (Schauta). The field of opera- 
tion may be made more accessible to the operator by 
tightly packing the vagina with iodoform gauze or intro- 
ducing a kolpeurynter. (The vagina, as well as the 
abdominal walls, should be carefully disinfected immedi- 
ately before the operation.) 

Before the abdominal wound is closed, a final inspec- 
tion should be made to determine whether anything, such 
as sponges or pads, has been left behind ; the nurse is 



124 OPERATIONS ON THE GENITAL ORGANS. 

Plate 34. 

Abdominal Hysterectomy (Freund).— Ligating the adnexa, The ab- 
dominal walls are held apart with Fritsch's retractors, being covered 
over with sterile cloths. The internal genitalia are in plain view. 
The left suspensory ligament of the ovary and the left round ligament 
have already been ligated. The uterine extremity of the tube is being 
tied. 

Plate 35. 

Abdominal Hysterectomy.— Division of the left broad ligament be- 
tween the ligatures, placed as shown on Plate 34. 

Plate 36. 

Abdominal Hysterectomy.— Ligation of the left uterine artery. The 
entire perimetrium of the left side has been exposed, partly by cutting 
and partly by blunt dissection of the two layers of the broad ligament, 
so that the uterine artery can be seen and felt to pulsate alongside of the 
ureter in the depths of the wound. The plate shows the method of 
passing a needle around the vessel. 

Plate 37- 

Abdominal Hysterectomy. — Amputation of the uterus and its removal 
from the vault of the vagina, The three principal ligatures that remain 
are visible. Similar ligatures have been placed on the right side, so that 
the amputation of the uterus is practically unattended by hemorrhage. 

always instructed to count sponges and pads both before 
and after the operation. [It is well that the chief assist- 
ant should do this also. — Ed.] The best way to close 
the abdominal wound is by several rows of sutures — at 
least two : (1) A suture uniting the peritoneum and the 
fascia ; (2) a suture uniting the muscle and skin. For the 
first, catgut is used ; and for the last, celluloid twine or 
gutta-percha silk, as these are not capillary, or aluminium 
bronze, or silver wire. The wound is then covered with 
an air-tight bandage, consisting, say, of iodoform collo- 



N 




ABDOMINAL HYSTERECTOMY. 125 

dion or Brims' airol paste and gauze. A circular ban- 
dage around the body, well padded with cotton, completes 
the dressing. In a normal case the woman stays in bed 
for two weeks and is discharged at the end of the third 
week. 

4. Abdominal Hysterectomy. 

This operation, according to Freund, is to be per- 
formed both in myomatosis and in carcinomatosis of the 
organ if the uterus, either on account of the tumors or on 
account of a complicating pregnancy, is too large, or if 
it is bound down by numerous large adhesions and can- 
not be removed through the vagina. The operation 
consists in removing the uterus, oviducts, and ovaries 
from the broad ligaments and from the vault of the 
vagina through the peritoneal cavity in such a way as to 
avoid hemorrhage and injury of neighboring organs, such 
as the bladder, the ureter, and the rectum. The ligation 
of the vessels compared to the same procedure in the 
vaginal operation is extremely simple, except the ligation 
of the uterine artery, as in the latter procedure there is 
greater danger of injuring or including the ureter because 
the bladder and ureters cannot be so thoroughly dissected 
away from the uterine arteries. 

The ligatures are placed on each side as follows : (1) 
One around the suspensory (infundibulopelvic) ligament 
of the ovary, laterally from the pavilion of the tube ; 
this includes the internal spermatic or ovarian arteries. 
(2) One including the utero-ovarian ligament and the 
uterine insertion of the tube with the arterial branches 
of the tubes and ovaries. (3) One ligature around the 



126 OPERATIONS ON THE GENITAL ORGANS. 

Plate 38. 

Abdominal Hysterectomy in a Case of Myoma of the Uterus. — Ketro- 
peritoneal treatmeut of the stump after Chrobak. Ligature of the 
uterine artery after the vessels and all ligaments have been tied, as in 
the last-described operation, In ligating tbe uterine artery the needle is 
at the same time passed through the Trails of tbe cervix. 

Plate 39. 

Abdominal Hysterectomy in a Case of Myoma of the Uterus. — 

Securing a flap from the posterior wall of tbe uterus for the purpose of 
covering the stump of the cervix (Chrobak). The ligatures described in 
the last operation have all been tied. 

Plate 40. 

Abdominal Hysterectomy in a Case of Myoma of the Uterus.— 
Wedge-shaped excision of the stump of the cervix. The ligatures about 
the uterine arteries are seen on both sides of the stump. The lumen of 
the cervix is vigorously disinfected and covered with the two tbick flaps, 
which have been made less rigid by excising portions of tissue and by 
dissection. 

Plate 41. 

Abdominal Hysterectomy in a Case of Myoma of the Uterus. — Clos- 
ing the peritoneal wouud. The wound in the broad ligaments is closed 
from one suspensory ligament of the ovary to the other with a continu- 
ous buried catgut suture. This includes subserous disposal of the stump 
of the cervix, which has already been sewed together and the sutures 
tied in the lumen of the cervix. 

Plate 42. 

Abdominal Hysteropexy or Ventrofixation of the Uterus (after 
Olshausen). — The round ligaments are secured by sutures to tbe peri- 
toneal wound. Czerny and Leopold pass the sutures through the fundus 
of the uterus. 



round ligament at about its center, which includes the 
arteries of the round ligament (see Plate 34). 

The broad ligament is now divided on the median side 
of the ligatures, the incision beginning at the insertion 



-* 

§ 




Tab. 42. 




,3 



SUPRAVAGINAL ABDOMINAL HYSTERECTOMY. 127 

of the tube into the suspensory ligament of the ovary 
and ending a little above the internal os, leaving the 
ligature of the round ligament a little to one side 
(Plate 35). 

At this point the pulsation of the uterine artery can be 
felt. The vessel is dissected out from the surrounding 
connective tissue, isolated from the ureter, and then 
ligated (Plate 36). After the cervico vaginal artery has 
also been secured, the uterus is separated from the 
bladder with a blunt instrument and one of the two 
vaults of the vagina is opened. Finding of the various 
structures will be greatly facilitated if the vagina has 
first been packed with gauze. After these preliminary 
steps the complete separation of the uterus from the 
vagina presents no difficulty (Plate 37). 

The vault of the vagina is closed separately, and after 
that the entire transverse wound in the parametrium, 
from one suspensory ligament of the ovary to the other, 
is closed with a continuous catgut suture which should 
also include once more the edges of the vaginal wound 
(Plate 41). If interrupted sutures are used, they must 
be so placed that the knots and ends of the sutures will 
be in the vagina. 

5. Supravaginal Abdominal Hysterectomy for Myoma. 

This operation is used in the case of tumors larger 
than a child's head ; in obstetric operations, to take the 
place of the conservative Cesarean section when the 
uterus is lacerated or has ruptured [If an infected uterus 
must be removed, total extirpation should be performed. — 
Ed.] or become infected and the ovum has escaped into 



128 OPERATIONS ON THE GENITAL ORGANS. 

the peritoneal cavity ; or prophylactically in the case of 
multipara? whose children are always still-born per vias 
naturales or cannot be delivered at all in any other way. 

The following description of a typical hysterectomy 
for uterine myoma is based in the main on Chrobak's 
method of securing the stump of the cervix retroperi- 
toneally. 

The operation is begun like the one just described, and 
no difference is made until the ligation of the uterine 
artery. In ligating this vessel the ligature is made to 
include the edge of the muscular wall of the uterus 
(Plate 38). Before the uterus is emptied, a muscular flap 
covered with serous membrane is excised from its poste- 
rior wall, large enough to cover the stump of the cervix 
and thick enough so that its vascular supply suffices to 
guard against necrosis (Plate 39). The stump of the 
cervix is cut out in wedge or funnel shape (Plate 40), so 
that the walls of the cervix can be sewed together as a 
protection against the passage upward of micro-organisms 
from the vagina and cervical canal. The sutures uniting 
the muscular tissue are buried by covering the entire 
stump with the serous flap. The sutures which close the 
serous flap form part of the line of sutures used to close 
the wound in the broad ligaments (Plate 41) described in 
the last operation. 

6. Ventrofixation of the Uterus. 

This operation, according to Olshausen, Czerny, and 
Leopold, is to be preferred to vaginofixation or the 
Alexander-Adams operation in younger women, because 
it does not interfere with labor. [The author evidently 



ALEX AN DEB- ADAMS OPERATION. 129 

means ventrosuspension. — Ed.] It is especially appro- 
priate in retroflexion with fixation of the uterus when the 
adhesions have been broken up. 

Olshausen secures the insertions of the round ligaments 
to the angles of the peritoneal wound and to the sheaths 
of the recti (Plate 42), while Czerny and Leopold pass 
the sutures through the fundus itself. The same sutures 
that are used to close the abdominal wall are passed 
through the fundus. Catgut may also be used. 

X. ALEXANDER=ADAMS OPERATION, PERFORMED 
AFTER EXPOSURE OF THE INGUINAL CANAL. 

Topographic and Surgical Anatomy of the Inguinal Region. 

The skin is divided immediately above Poupart's liga- 
ment and in a direction parallel with it, then the panniculus 
adiposus, and, underneath that, the superficial abdominal 
fascia, in which, midway between the symphysis and the 
anterior superior spine of the ilium, the epigastric vessels 
will be found. The superficial fascia is divided only by a 
thin layer of fat from the much thicker aponeurosis of the 
external oblique. The latter covers and forms the in- 
guinal canal, the internal opening of which is situated at 
a point somewhat lateral to the epigastric vessels. The 
external inguinal ring is situated a short distance to the 
outer side of the pubic tubercle, which can be readily 
palpated. It is formed by the aponeurosis of the external 
oblique (intercrural fibers), wdiich here undergo division 
and form the radiating crura Ugamenti inguinalis superkcs 
et inferius. The opening is covered by the thin cremas- 
teric fascia. Between the limbs of the inguinal ring the 

9 



130 ALEXANDER-ADAMS OPERATION. 

round ligament emerges with the ilio-inguinal nerve. The 
latter courses downward and crosses the external pudendal 
vein on the ligament. Behind these structures the ex- 
ternal spermatic nerve runs down and sends one branch 
behind the ligament and upward from this point. 

The round ligament can, therefore, be followed along 
with the ilio-inguinal nerve laterally into the inguinal 
canal. To expose the round ligament and the nerve, the 
aponeurosis must be divided in a line parallel with Pou- 
part's ligament, from the pubic tubercle or external 
inguinal ring to the anterior superior spine of the ilium, 
a distance of 7 or 8 centimeters from the symphysis. The 
posterior Avail of the canal, formed by the transversalis 
fascia and the reflected inguinal ligament, is then exposed. 
Near the internal inguinal ring there is a sac-like pro- 
tuberance on the outer side of the round ligament. This 
is the 'peritoneal diverticulum of Nuck, the vaginal process 
of the peritoneum which is loosely united to the round 
ligament. The internal, like the external, inguinal ring 
is bounded by aponeurosis, the boundary of the in- 
ternal ring being a portion of the transversalis fascia — 
namely, the semilunar fold. Behind or underneath the 
inguinal canal we come upon the deep epigastric vessels. 

AIexander=Adams Operation of Shortening the Round 
Ligament. 

The topography having thus been described, the steps 
of the operation are as follows : A curved incision is 
carried from the pubic tubercle to the anterior superior 
spine of the ilium, a little above and parallel with Pou- 
part's ligament. The epigastric vessels must be avoided. 



ALEXANDER-ADAMS OPERATION. 131 

About the middle of the incision the aponeurosis of the 
external oblique is dissected out, and the external inguinal 
ring is then found. This structure is recognized by the 
intercrural fibers and the inguinal crura. This procedure 
is attended with the division of the branches of the 
above-described blood-vessels, and the resulting hemor- 
rhage obscures the view. Werth avoids this by directly 
dividing the aponeurosis and laying open the inguinal 
canal. 

The round ligament is then carefully drawn out of the 
canal for a distance of about 10 cm. If more than this 
is drawn out, the uterus tips over backward, because 
peritoneal fibers in the broad ligament are put on the 
stretch and thus bring about a retroversion of the organ 
(Zweifel). The diverticulum of Nuck (Nuck's canal) is 
drawn out at the same time with the round ligament and 
may be opened when the ligament is shortened. 

The fixation sutures should close both the peritoneal 
sac and the inguinal canal. They are accordingly carried 
from the external oblique through the round ligament and 
through the two serous edges to Pouparr's ligament. 
Interrupted catgut sutures are used ; the wound is finally 
closed by means of deep through-and -through sutures. 



INDEX. 



Abdominal cavity, operations 
requiring opening of, 120 
hysterectomy, 125, Pis. 34-37 
in myoma of uterus, 127, Pis. 
38^41 
hysteropexy, 128, PI. 42 
wall, celiotomy with ordinary 
median incision through, 
122 
Ahrasio mucosae, 81 
Abscess, pelvic, opening of, 96 
Accouchement force, 79 
Adnexa, operations on, 102 
Alexander- Adams operation after 
exposure of inguinal canal, 
129 
for shortening round liga- 
ment, 130 
Amputation of cervix uteri, su- 
pravaginal, 92 
Anococcygeal ligament, 21 
Atmokausis, 83 

Barnes' hags, 80 

Bischoflf's kolpoperineorrhaphy, 

35 
Bladder, relations of vagina to, 74 
boundary of, 97 

foreign bodies in, kolpocystot- 
omy for, 59, 61. PI. 11 



Bladder, foreign bodies in, removal 
of, through urethra, 59, 
61, PI. 11 

Broad ligament, 75 

Bulbocavernosus muscle, 24 

Castration, 103, Pis. 26, 27, 28 
Cavum praevesicale superius, 115 
Celiotomy, operations on genitals 
requiring, 114 
with ordinary median incision 
through abdominal wall, 
122 
Cervical canal, dilatation of, 79 
of uterus, artificial dilatation 
of, operations after, 72 
Cervicitis, 68, PI. 16 

Schroder's wedge-shaped inci- 
sion for, 70 
Cervico-ureteral fistula, operation 

for closure of, 94 
Cervicovesical fistula, operation 

for closure of, 94 
Cervix, excision of, double- 
wedged, 69, PI. 15 
uteri, amputation of, suprava- 
ginal, 92 
bloodless dilatation of, 78 
retrofixation of, 106 
Coccygeal muscles, 20 

133 



134 



INDEX. 



Columnar rugarum vaginae, 18 

Constrictor cunni, 24 

Crura ligamenti inguinalis super- 

ius et inferius, 129 
Curetment, 81 



Descending limb of tube, 117 
Diaphragm of pelvis, 20 
Diverticulum of Nuck, peritoneal, 

130 
Douglas' pouch, 47 

abscess in, operative treat- 
ment, 107 

atrium of, 119 

fundus of, 119 

opening of, PI. 3 

posterior, operations per- 



Ectopic gestation, operative treat- 
ment, 106 
Emmet's operation for commis- 
sural lacerations, 68 
Episiotomy, 43 
Epoophoron, 118 
Eversion of cervical mucosa, 68, 
PI. 16 
Schroder's incisions for, 70 
External inguinal ring, 129 
oblique, 114 
os, discission of, 67 
sphincter ani, 23 
Extirpation, total, of uterus 
through vagina, Pis. 29, 
30, 31, 32, 33 

Fibromyoma, polypous, enuclea- 
tion of, 88, Pis. 20-23 



Fibromyoma, subserous, of uterus, 

removal, 101 
Eistula, cervico-ureteral, operation 

for closure of, 94 
cervicovesical, operation for 

closure of, 94 
uretero vaginal, Mackenrodt's 

method of closing, 95 
vesicovaginal, traumatic, opera- 
tions for, 59 
Eossa navicularis, repair of injury 

to, 33 
Freund's kolpoperineorrhaphy, 

36, 38 
Fritsch's kolpoperineorrhaphy, 34, 

35 
Fundus vesicae, 116 

Genitals, anatomy, 114 

operations on, requiring celiot- 
omy, 114 
surgical anatomy, 114 
topographic anatomy, 114 
G-ersuny's operation for incon- 
tinence of urine, 44 
Gestation, ectopic, operative 

treatment, 106 
Gravid accessory cornu, removal, 
102 

Hegar's kolpoperineorrhaphy, 

35, 49, Pis. 4-8. 
Hymen, extirpation of portions 

of, 43 
Hypogastric-inguinal region, 

oblique incision in, 121 
Hysterectomy, abdominal, 125, 

Pis. 34-37 



INDEX. 



135 



Hysterectomy for myoma of ute- 
rus, 127, Pis. 38-41 

Hysterocleisis, 71 

Hysteropexy abdominal, 128, PL 
42 

Impresio uterina, 115 
Incision, median, through abdomi- 
nal wall, celiotomy with, 
122 
oblique, in hypogastric-inguinal 

region, 121 
transverse, in suprapubic re- 
gion, 121 
Incontinence of urine, operation 

for, 44 
Infradiaphragmatic hollow organs, 

23 
Inguinal canal, anatomv. 129 

exposure of, Alexander- 
Adams operation after, 
129 
surgical anatomy, 129 
topographic anatomy, 129 
ring, external, 129 
internal, 130 
Internal inguinal ring, 130 

oblique, 114 
Intestine, ovary and, 118 
Ischiocavernosus muscle, 24 
Ischiorectal fossa, 23 

Kohlratjsch's fold, 47 
Kolpoceliotomy, anterior, 97, Pis. 
24, 25-Fig. 1 
operations on uterus with aid 

of, 101 
ovariotomy after, 103, Pis. 
26-28 



Kolpoceliotomy, anterior, vagini- 
fixation of uterus after, 98, 
PI. 25-Pig. 2 
in pelvic abscess, 104 
posterior, 105 
Kolpocleisis, 71 
Kolpocystotomy, 61, PI. 11 

for foreign bodies in bladder, 59, 
61, PI. 11 
Kolpoperineorrhaphy, 34, 49, Pis. 
4-8 
Bischoff's, 35 
Freund's, 36, 38 
Fritsch's, 34, 35 
Hegar's, 35, 49, Pis. 4-8 
with retrofixation of cervix, 49, 
Pis. 4-8 
of neck, PI. 3 
Kolporrhaphy, anterior, 56, PI, 9 

posterior, 49, 52 
Kolporrhaphy - perineorrhaphy, 

Martin's, 38 
Kolpotomy, anterior, 97, Pis. 24. 
25-Fig. 1 

Levator ani muscle, 20 
Levatores ani et trigoni urethro- 

genitalis, 18 
Linea alba, 114 
Luschka's muscle, 119 
Lymph oglandul?e hypogastrics, 

76 

Mackenrodt's method of closing 
ureterovaginal fistula, 95 

Martin 's kolporrhaphy-perineor- 
rhaphy, 38 

Menorrhagia, atmokausis for, 83 

Mesosalpinx, 118 



136 



INDEX. 



Mesovarium, 117 
Metreurynter, method of using, 80 
Metrorrhagia, atmokausis for, 83 
Musculus trigoni urogenitals, 21 

Buck's canal, 130 

Oblique incision in hypogastric- 

inguinal region, 121 
Operations on genitals requiring 
celiotomy, 114 
performed after opening one or 
both peritoneal pouches and 
wall of uterus, 109 
through posterior pouch of 

Douglas, 104 
without speculum, 17 
requiring exposure of vagina, 46 
requiring opening of abdominal 

cavity, 120 
requiring opening of vesico-uter- 
ine fossa, 96 
Os, commissures of, lacerations of, 
68 
Emmet's operation, 68 
Ovarian tube, descending limb of, 
117 
intestines and, 118 
position of, 117 
tumors, removal of, 103, Pis. 26, 
27, 28 
Ovariotomy after anterior kolpo- 
celiotomy, 103, Pis. 26, 27, 
28 
Ovary, intestines and, 118 
position of, 117 

Parametria, opening abscess in, 
96 



Parametria, true, 75 
Paroophoron, 118 
Pelvic abscess, kolpoceliotomy in, 
104 
opening of, 96 
floor, anatomy of, 17, 19 
openings, 21 
Pelvis, blood supply, 22 

diaphragm of, 20 
Perimetrium, 118 
Perineal region, inner, surgical 

topography, 18 
Perineoplastic operations in the 

flaps, 39 
Perineoplasty, Bischoff, 35, 36 
Perineorrhaphy, 25 

for complete lacerations, 26, Pis. 
1,2 
after-treatment, 31 
cicatrized, 32 
granulating, 32 
needle, 29 

preliminary treatment, 29 
secondary operation, 32 
suture material, 29 
for incomplete lacerations, 33 

cicatrized, 33 
von Winckel's, 38 
Perineorrhaphy - kolporrhaphy, 

Martin's, 38 
Perineum, anatomy, 18 
lacerations of, 25 

repair of, 25. See also Perin- 
eorrhaphy. 
operations on, 24 

complete plastic, 26, Pis. 
1,2 
rectovaginal fistula near, closing 
of, 66 



INDEX. 



137 



Peritoneal diverticulum of Nuck, 
120 
fossa, 116 

pouch and wall of uterus, oper- 
ations performed after open- 
ing, 109 
obliteration of, 106 
total extirpation of uterus 
through vaginal opening 
in, 111 
Peri-uterine space, 115 
Perivesical space, 115 
Plica epigastrica, 115 

peritonealis, 116 
Plicse vesical es transversa, 115 
Polypoid fibromyoma, enucleation 

of, 88, Pis. 20-23 
Polyps, removal. 83 
Portio vaginalis, 48 
anatomy, 46 
operations on, 67 
wall of, wedge-shaped exci- 
sion from, 69, PI. 15 
Pouch of Douglas, abscess in, 
operative treatment 107 
atrium of, 119 
fundus of, 119 

posterior, operations per- 
formed through, 104 
peritoneal, and wall of uterus, 
operations performed after 
opening of, 109 
obliteration of, 106 
total extirpation of uterus 
through vagina by opening 
of, 111 
Pregnancy, vaginifixation and, 99 
Prevesical space, 115 
Pyriform muscles, 20 



Kaclage, 81 

Recessus pararectales, 120 

Recto-uterine folds, 119 
fossa, 119 

Rectovaginal fistula, high method 
of closing, 66, Pis. 13, 14 
near perineum, closing of, 66 

Rectum, 23 

Reinversion, 109 

Retrofixation of cervix uteri, 106 

Round ligament, Alexander- 
Adams operation for short- 
ening, 130 

Sacci pararectales, 120 
Sacrorecto-uterine ligaments, 119 
Schroder's wedge-shaped incision, 

70, PI. 16 
Speculum, operations performed 

without, 17 
Sterilization, 103, Pis. 26-28 
Suprapubic region, transverse in- 
cision in, 121 

Torus uterinus, 119 
Trans versalis fascia, 114 
Transverse incision in suprapubic 

region, 121 
Transversus perinsei muscle, 24 
Trigonum Lieutaudii, 48 

urogenitale, 21 
True parametria, 75 

Ureterovaginal fistula, Mac- 
kenrodt's method of closing, 
95 

Urethra, dilatation of, 59 

removal of foreign bodies in 
bladder through, 59, PI. 11 



138 



INDEX. 



Urethra, resection of, 45 
Urethral region, inner, surgical 

topography, 18 
Urine, incontinence of, operation 

for, 44 
Uterine artery, ligation of, 89 

cavity, vaporization of, 83 
Uterus, attachments of, 118 

cervical canal of, artificial dila- 
tation of, operations after, 
72 
cervix of. See Cervix uteri. 
extirpation of, ligation of uter- 
ine artery, 89 
myoma of, abdominal hysterec- 
tomy in, 127, Pis. 38-41 
operations on, with aid of an- 
terior kolpoceliotomy, 101 
performed after opening wall 
of, and one or both peri- 
toneal pouches, 109 
position, 118 
sounding of, 78 

subserous fibromyoma of, re- 
moval, 101 
total extirpation of, through 
vagina, Pis. 29-33 
by opening peritoneal 
pouches, 111 
vaginifixation of, after kolpo- 
celiotomy, 98, PI. 25- 
Pig. 2 
ventrofixation of, 128, PI. 42 

Vagina, anatomy, 46 
anterior vault, 72 
bladder and, relations of, 74 
cervix of, anatomy, 72 
blood supply, 75 



Yagina, cervix of, division of an- 
terior wall of, 85, Pis. 17-19 
supravaginal amputation, 85, 

Pis. 17-19 
wall of, 76 
lumen of, 48 

narrowing of, 57, PI. 10 
surgical anatomy, 46 
topographic anatomy, 46 
total extirpation of uterus 
through, Pis. 29-33 
by opening peritoneal 
pouches, 111 
vaults of, anatomy, 72 
blood supply, 75 
operations after dissecting 
away of, 85 
Vaginifixation, 98, PI. 25-Pig. 2 
precautions, 99 
pregnancy and, 99 
sutures, 100 
Vaginifixura vesicofixatio uteri, 
98, PI. 25-Pig. 2 
precautions, 99 
pregnancy and, 99 
sutures, 100 
Vaginorrhaphy, high, 57, PL 10 
Vaporization of uterine cavity, 83 
Ventrofixation, 128, PI. 42 
Vesi co-uterine fossa, 116 

operations requiring opening 
of, 96 
Vesicovaginal fistula, flap-split- 
ting method, 64 
method of closing, 62, PI. 12 
traumatic, operation for, 59 
von Winckel's perineorrhaphy, 38 
Vulva, extirpation of parts of, 43 
operations on, 24 



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lence of text and illustration are commendable." 

Journal of Ophthalmology, Otology, and Laryngology 

" A collection of the most naturally colored lithographic plates that has been pub- 
lished in any book in the English language. . . . Very valuable alike to the student, the 
practitioner, and the specialist." 

Each volume contains from 50 to 100 colored plates 



SAUNDERS' MEDICAL HAND-ATLASES 

Helferich and Bloodg'ood*s 
Fractures and Dislocations 



Atlas and Epitome of Traumatic Fractures and Dis= 
locations. By Professor Dr. H. Helferich, Professor of 
Surgery at the Royal University, Greifswald, Prussia. Edited, 
with additions, by Joseph C. Bloodgood, M. D., Associate in 
Surgery, Johns Hopkins University, Baltimore. From the Fifth 
Revised and E?ilarged German Edition. With 216 colored 
illustrations on 64 lithographic plates, 190 text-cuts, and 353 
pages of text. Cloth, $3.00 net. 

SHOWING DEFORMITY, X-RAY SHADOW, AND TREATMENT 

This department of medicine being one in which, from lack of practical 
knowledge, much harm can be done, and in which in recent years great 
importance has obtained, a book, accurately portraying the anatomic rela- 
tions of the fractured parts, together with the diagnosis and treatment of the 
condition, becomes an absolute necessity. This present work fully meets 
all requirements. As complete a view as possible of each case has been 
presented, thus equipping the physician for the manifold appearances that 
he will meet with in practice. The illustrations show the visible external 
deformity, the X-ray shadow, the anatomic preparation, and the method of 
treatment. 



OPINIONS OF THE MEDICAL PRESS 



Medical News, New York 

" This compact and exceedingly attractive little volume will be most welcome to al 1 
who are interested in the practical application of anatomy. The author and editor have 
made a most successful effort to arrange the illustrations that the interpretation of what 
they are intended to present is exceedingly easy." 

Brooklyn Medical Journal 

" There are few books published that better answer the requirements for illustration 
than this work of Professor Helferich. ... Such a collection of illustrations must oe the 
result of much labor and thought." 

They are Satisfactory Substitutes for Clinical Observation 



SAUNDERS' MEDICAL HAND-ATLASES 



Sultan and Coley's 
Abdominal Hernias 



Atlas and Epitome of Abdominal Hernias. By Privat- 
docent Dr. Georg Sultan, of Gottingen. Edited, with addi- 
tions, by William B. Coley, M. D., Clinical Lecturer on Sur- 
gery, Columbia University (College of Physicians and Surgeons), 
New York. With 119 illustrations, 36 of them in colors, and 
2 77 pages of text. Cloth, $3.00 net. 

DEALING WITH THE SURGICAL ASPECT 

This new atlas covers one of the most important subjects in the entire 
domain of medical teaching, since these hernias are not only exceedingly 
common, but the frequent occurrence of strangulation demands extraordi- 
narily quick and energetic surgical intervention. During the last decade the 
operative side of this subject has been steadily growing in importance, until 
now it is absolutely essential to have a book treating of its surgical aspect. 
This present atlas does this to an admirable degree. The illustrations are 
not only very numerous, but they excel, in the accuracy of the portrayal of 
the conditions represented, those of any other work upon abdominal hernias 
with which we are familiar. The work will be found a worthy exponent 
of our present knowledge of the subject of which it treats. 



PERSONAL AND PRESS OPINIONS 



Robert H. M. Dawbarn, M. D., 

Professor of Surgery and Surgical Anatomy, New York Polyclinic. 

" I have spent several interested hours over it to-day, and shall willingly recommend 
it to my classes at the Polyclinic College and elsewhere." 

Boston Medical and Surgical Journal 

" For the general practitioner and the surgeon it will be a very useful book for reference. 
The book's value is increased by the editorial notes of Dr. Coley." 

They have already appeared in thirteen different languages 



SAUNDERS' MEDICAL HAND-ATLASES 7 

Brtihl, Politzer, and 
MacCuen Smith's Otology 



Atlas and Epitome of Otology. By Gustav Bruhl, M. D., 
of Berlin, with the collaboration of Professor Dr. A. Politzer, 
of Vienna. Edited, with additions, by S. MacCuen Smith, 
M. D., Clinical Professor of Otology, Jefferson Medical Col- 
lege, Philadelphia. With 244 colored figures on 39 lithographic 
plates, 99 text-illustrations, and 292 pages of text. Cloth, $3.00 
net. 

INCLUDING ANATOMY AND PHYSIOLOGY 

This excellent volume is the first attempt to supply in English an illus- 
trated clinical handbook to act as a worthy substitute for personal instruction 
in a specialized clinic. This work is both didactic and clinical in its teach- 
ing, the latter aspect being especially adapted to the student's wants. A 
special feature is the very complete exposition of the minute anatomy of the 
ear, a working knowledge of which is so essential to an intelligent concep- 
tion of the science of otology. The illustrations are beautifully executed in 
colors, and illuminate the text in a singularly lucid manner, portraying patho- 
logic changes with such striking exactness that the student should receive a 
deeper and more lasting impression than the most elaborate description 
could produce. Further, the association of Professor Politzer in the prepa- 
ration of the work, and the use of so many valuable specimens from his 
notably rich collection especially enhance the value of the work. The text 
contains everything of importance in the elementary study of otology. 



PERSONAL AND PRESS OPINIONS 



Clarence J. Blake, M. D., 

Professor of Otology, Harvard University Medical School, Boston. 
" The most complete work of its kind as yet published, and one commending itself to 
both the student and teacher in the character and scope of its illustrations." 

Boston Medical and Surgical Journal 

"Contains what is probably the best collection of colored plates of the ear, both of 
normal and pathological conditions, of any hand-book published in the English language. 
In addition to this the text is presented in an unusually clear and direct manner." 

They are offered at a price heretofore unapproached in cheapness 



; SAUNDERS' MEDICAL HAND-ATLASES 

Lehmann, Neumann, and 
Weaver's Bacteriology 



Atlas and Epitome of Bacteriology : including a Text- 
Book of Special Bacteriologic Diagnosis. By Prof. Dr. 
K. B. Lehmann and Dr. R. O. Neumann, of Wiirzburg. From 
the Second Revised a?id Enlarged German Edition. Edited, 
with additions, by G. H. Weaver, M. D., Assistant Professor 
of Pathology and Bacteriology, Rush Medical College, Chicago. 
In two parts. Part I. — 632 colored figures on 69 lithographic 
plates. Part II. — 511 pages of text, illustrated. Per part: 
Cloth, $2.50 net. 

INCLUDING SPECIAL BACTERIOLOGIC DIAGNOSIS 

This work furnishes a survey of the properties of bacteria, together with 
the causes of disease, disposition, and immunity, reference being constantly 
made to an appendix of bacteriologic technic. The special part gives a 
complete description of the important varieties, the less important ones being 
mentioned when worthy of notice. The lithographic plates, as in all this 
series, are accurate representations of the conditions as actually seen, and 
this collection, if anything, is more handsome than any of its predecessors. 
As an aid in original investigation the work is invaluable. 



OPINIONS OF THE MEDICAL PRESS 



American Journal of the Medical Sciences 

" Practically all the important organisms are represented, and in such a variety of 
forms and cultures that any other atlas would rarely be needed in the ordinary hospital 
laboratory." 

The Lancet, London 

" We have found the work a more trustworthy guide for the recognition of unfamiliar 
species than any with which we are acquainted." 

There have been 82,000 copies imported since publication 



SAUNDERS' MEDICAL HAND- ATLASES 

Zuckerkandl and OaCosta's 
Operative Surgery 

Second Edition, Revised and Greatly Enlarged 



Atlas and Epitome of Operative Surgery. By Dr. 0. 

Zuckerkandl, of Vienna. Edited, with additions, by J. Chal- 
mers DaCosta, M. D., Professor of the Principles of Surgery 
and Clinical Surgery, Jefferson Medical College, Philadelphia. 
With 40 colored plates, 278 text-cuts, and 410 pages of text. 
Cloth, $3.50 net. 

ADOPTED BY THE U. S. ARMY 

In this new edition the work has been brought precisely down to date. 
The revision has not been casual, but thorough and exhaustive, the entire 
text having been subjected to a careful scrutiny, and many improvements and 
additions made. A number of chapters have been practically rewritten, and 
of the newer operations, all those of special value have been described. The 
number of illustrations has also been materially increased. Sixteen valuable 
lithographic plates in colors and sixty-one text-figures have been added, thus 
greatly enhancing the value of the work. There is no doubt that the volume 
in its new edition will still maintain its leading position as a substitute for 
clinical instruction. 



OPINIONS OF THE MEDICAL PRESS 



Philadelphia Medical journal 

"The names of Zuckerkandl and DaCosta, the fact that the book has been translated 
into 13 different languages, together with the knowledge that it is used in the United States 
Army and Navy, would be sufficient recommendation for most of us." 

Munchener Medicinische Wochenschrift 

"We know of no other work that combines such a wealth of beautiful illustrations with 
clearness and conciseness of language, that is so entirely abreast of the latest achievements, 
and so useful both for the beginner and for one who wishes to increase his knowledge of 
operative surgery." 

Each volume is edited, with additions, by a leading specialist 



io SAUNDERS' MEDICAL HAND-ATLASES 

Dtirck and ffektoen's 
Special Pathologic Histology 



Atlas and Epitome of Special Pathologic Histology. 

By Dr. H. Durck, of Munich. Edited, with additions, by 
Ludvig Hektoen, M. D., Professor of Pathology, Rush Medi- 
cal College, Chicago. In Two Parts. Part L— Circulatory, 
Respiratory, and Gastro-intestinal Tracts. 120 colored figures 
on 62 plates, and 158 pages of text. Part II. — Liver, Urinary 
and Sexual Organs, Nervous System, Skin, Muscles, and Bones. 
123 colored figures on 60 plates, and 192 pages of text. Per 
part : Cloth, $3.00 net. 

A RARE COLLECTION OF BEAUTIFUL PLATES 

The colored lithographs of this volume are beautifully reproduced, and 
are extremely accurate representations of the microscopic changes produced 
by disease. The great value of these plates is that they represent in the 
exact colors the effect of the stains, which is of such great importance for 
the differentiation of tissue. The text portion of the book is admirable, and, 
while brief, it is entirely satisfactory in that the leading facts are stated, and 
so stated that the reader feels he has grasped the subject extensively. The 
work is modern and scientific, and altogether forms a concise and systematic 
view of pathologic knowledge. 



PERSONAL OPINIONS 



William H. Welch, M. D., 

Professor of Pathology, Johns Hopkins University, Baltimore. 

" I consider Diirck's ' Atlas of Special Pathologic Histology,' edited by Hektoen, a very 
useful book for students and others. The plates are admirable." 

Frank B. Mallory, M. D., 

Assistant Professor of Pathology, Harvard University Medical School, Boston. 
" The information is presented in a very compact form ; it is carefully arranged, briefly 
and clearly stated, and almost always represents our latest knowledge of the subject." 

They represent the best artistic and professional talent 



SAUNDERS' MEDICAL HAND-ATLASES 

Haab and deSchweinitz's 
Ophthalmoscopy 



Atlas and Epitome of Ophthalmoscopy and Ophthal- 
moscopic Diagnosis. By Dr. O. Haab, of Ziirich. From the 
Third Revised and Enlarged German Edition. Edited, with 
additions, by G. E. deSchweinitz, M. D., Professor of Oph- 
thalmology, University of Pennsylvania. With 152 colored 
lithographic illustrations; 85 pages of text. Cloth, $3.00 net. 

Not only is the student made acquainted with carefully prepared oph- 
thalmoscopic drawings done into well-executed lithographs of the most 
important fundus changes, but, in many instances, plates of the microscopic 
lesions are added. It furnishes a manual of the greatest possible service. 

The Lancet, London 

" We recommend it as a work that should be in the ophthalmic wards or in the library 
of every hospital into which ophthalmic cases are received." 

Haab and deSchweinitz's 
External Diseases of Eye 

Atlas and Epitome of External Diseases of the Eye. 

By Dr. O. Haab, of Zurich. Edited, with additions, by G. E. 
deSchweinitz, M. D., Professor of Ophthalmology, University 
of Pennsylvania. 88 colored illustrations on 48 lithographic 
plates and 232 pages of text. Cloth, $3.00 net. 

SECOND REVISED EDITION— JUST ISSUED. 

In this thorough revision the text has been brought up to date by the addi- 
tion of new matter, including references to some of the modern therapeutic 
agents. There have also been added eight chromolithographic plates. 

The Medical Record, New York 

" The work is excellently suited to the student of ophthalmology and to the practising 
physician. It cannot fail to attain a well-deserved popularity." (Review of previous ed.) 

They are convenient in size and uniformly bound 



12 SAUNDERS' MEDICAL HAND-ATLASES 

Schaffer and Edgar's 
Labor and Operative Obstetrics 

Atlas and Epitome of Labor and Operative Obstetrics. 

By Dr. 0. Schaffer, of Heidelberg. From the Fifth Revised 
and Enlarged German Edition. Edited, with additions, by 
J. Clifton Edgar, M. D., Professor of Obstetrics and Clinical 
Midwifery, Cornell University Medical School. 14 lithographic 
plates in colors; 139 other cuts; in pages of text. $2.00 net. 

The book presents the act of parturition and the various obstetric opera- 
tions in a series of easily understood illustrations. These are accompanied 
by a text that treats the subject from a practical standpoint. 

Dublin Journal of Medical Science, Dublin 

" One fault Professor Schaffer's Atlases possess. Their name, and the extent and 
number of the illustrations, are apt to lead one to suppose that they are merely ' atlases,' 
whereas the truth really is they are also concise and modern epitomes of obstetrics." 

Schaffer & Edgar's Obstetric 
Diagnosis and Treatment 

Atlas and Epitome of Obstetric Diagnosis and Treat- 
ment. By Dr. O. Schaffer, of Heidelberg. From the Sec- 
ond Revised German Edition. Edited, with additions, by J. 
Clifton Edgar, M. D., Professor of Obstetrics and Clinical 
Midwifery, Cornell University Medical School. 122 colored fig- 
ures on 56 plates; 38 other cuts; 315 pages of text. $3.00 net. 

This book treats particularly of obstetric operations, and, besides the 
wealth of beautiful lithographic illustrations, contains an extensive text of 
great value. This text deals with the practical, clinical side of the subject. 

New York Medical Journal 

" The illustrations are admirably executed, as they are in all of these atlases, and the 
text can safely be commended, not only as elucidatory of the plates, but as expounding the 
scientific midwifery of to-day." 

These are the famous " Lehmann medicinische Handatlanten " 



SAUNDERS' MEDICAL HAND-ATLASES 



«3 



Mracek and Stelwagon's 
Skin 

Atlas and Epitome of Diseases of the Skin. By Prof. 
Dr. Franz Mracek, of Vienna. Edited, with additions, by 
Henry W. Stelwagon, M. D., Clinical Professor of Derma- 
tology, Jefferson Medical College, Philadelphia. With 63 colored 
plates, 39 half-tone illustrations, and 200 pages of text. Cloth, 
$3.50 net. 

This volume, the outcome of years of scientific and artistic work, con- 
tains, together with colored plates of unusual beauty, numerous illustrations 
in black, and a text comprehending the entire field of dermatology. The 
illustrations are all original and prepared from actual cases in Mracek' s clinic. 

American Journal of the Medical Sciences 

"The advantages which we see in this book and which recommend it to our minds are : 
First, its handiness; secondly, the plates, which are excellent as regards drawing, color, 
and the diagnostic points which they bring out. We most heartily recommend it." 

Mracek and Bang's 
Syphilis and Venereal Diseases 

Atlas and Epitome of Syphilis and the Venereal Dis= 

eases. By Prof. Dr. Franz Mracek, of Vienna. Edited, with, 
additions, by L. Bolton Bangs, M. D., late Prof, of Genito- 
urinary Surgery, University and Bellevue Hospital Medical 
College, New York. With 71 colored plates and 122 pages 
of text. Cloth, $3.50 net. 

According to the unanimous opinion of numerous authorities, to whom 
the original illustrations of this book were presented, they surpass in beauty 
anything of the kind that has been produced in this field, not only in Ger- 
many, but throughout the literature of the world. 

Robert L. Dickinson, M. D., 

Art Editor of " The American Text-Book of Obstetrics." 

Si The book that appeals instantly to me for the strikingly successful, valuable, and 
graphic character of its illustrations is the ' Atlas of Syphilis and the Venereal Diseases.' 
I know of nothing in this country that can compare with it." 

The lithographs, all made in Germany, are unrivalled 



14 SAUNDERS' MEDICAL HAND-ATLASES 

Schaffer and Webster's 
Operative Gynecology 

Atlas and Epitome of Operative Gynecology. By Dr. 

O. Schaffer, of Heidelberg. Edited, with additions, by J. 
Clarence Webster, M. D. (Edin.), F. R. C. P. E., Professor of 
Obstetrics and Gynecology in the Rush Medical College, in affili- 
ation with the University of Chicago. With 42 lithographic 
plates in colors, many text-cuts, a number in colors, and 138 
pages of text. Cloth, $3.00 net. 

JUST ISSUED 

The excellence of the lithographic plates and the many other illustrations 
in this atlas render it of the greatest value in obtaining a sound and practical 
knowledge of operative gynecology. Indeed, the artist, the author, and the 
lithographer have expended much patient endeavor in the preparation of the 
water-colors and drawings. They are based on hundreds of photographs 
taken from nature, and they reproduce faithfully and instructively the various 
situations. The text closely follows the illustrations, and is fully as accurae. 

Shaffer and Norris* 
Gynecology 

Atlas and Epitome of Gynecology. By Dr. O. Shaffer, 

of Heidelberg. From the Second Revised and Enlarged German 

Edition. Edited, with additions, by Richard C. Norris, A. M., 

M. D., Gynecologist to Methodist-Episcopal and Philadelphia 

Hospitals. With 207 colored figures on 90 plates, 65 text-cuts, 

and 308 pages of text. Cloth, $3.50 net. 

The value of this atlas will be found not only in the concise explanatory 
text, but especially in the illustrations. The large number of colored plates, 
reproducing the appearance of fresh specimens, will give the student a knowl- 
edge of the changes induced by disease that cannot be obtained from mere 
description. 

Bulletin of Johns Hopkins Hospital, Baltimore 

" The book contains much valuable material. Rarely have we seen such a valuable 
collection of gynecological plates." 

These books are next best to actual clinical work 



SAUNDERS' MEDICAL HAND- A TEASES 15 

Jakob and Eshner's 
Internal Medicine & Diagnosis 

Atlas and Epitome of Internal Medicine and Clinical 
Diagnosis. ' By Dr. Chr. Jakob, of Erlangen. Edited, with 
additions, by Augustus A. Eshner, M. D., Professor of Clin- 
ical Medicine in the Philadelphia Polyclinic. With 182 colored 
figures on 68 plates, 64 illustrations in black and white, and 
259 pages of text. Cloth, $3.00 net. 

In addition to an admirable atlas of clinical microscopy, this volume 
describes the physical signs of all internal diseases in an instructive manner 
by means of fifty colored schematic diagrams. As a means of instruction 
its value is very great ; as a reference handbook it is admirable. 

British Medical Journal 

" Dr. Jakob's work deserves nothing but praise. The information is accurate and up 
to present-day requirements." 

Griinwald and Grayson's 
Diseases of the Larynx 



Atlas and Epitome of Diseases of the Larynx. By Dr. 

L. Grunwald, of Munich. Edited, with additions, by Charles 
P. Grayson, M. D., Physician-in- Charge, Throat and Nose 
Department, Hospital of the University of Pennsylvania. With 
107 colored figures on 44 plates, 25 text-illustrations, and 103 
pages of text. Cloth, $2.50 net. 

This atlas exemplifies a happy blending of the didactic and clinical, such 
as is not to be found in any other volume upon this subject. The author 
has given special attention to the clinical portion of the work, the sections 
on diagnosis and treatment being particularly full. - 

The Medical Record, New York 

" This is a good work of reference, being both practical and concise. ... It is a valu- 
able addition to existing laryngeal text-books." 

For " Special Offer " regarding these atlases see page I 



16 SAUNDERS' MEDICAL HAND-ATLASES 

Hofmann and Peterson's 
Legal Medicine 

Atlas of Legal Medicine. By Dr. E. von Hofmann, of 
Vienna. Edited by Frederick Peterson, M. D., Professor of 
Psychiatry, College of Physicians and Surgeons, N. Y. 120 colored 
figures on 56 plates, 193 half-tone illustrations. Cloth, $3.50 net. 
The Practitioner, London 

" The illustrations appear to be the best that have ever been published in connection 
with this department of medicine, and they cannot fail to be useful alike to the medical 
jurist and to the student of forensic medicine." 

Jakob and Fisher's 
Nervous System and its Diseases 

Atlas and Epitome of the Nervous System and its 
Diseases. By Prof. Dr. Chr. Jakob, of Erlangen. From the 
Second Revised German Edition. Edited, with additions, by 
Edward D. Fisher, M. D., Professor of Diseases of the Nervous 
System, University and Bellevue Hospital Medical College, N. Y. 
83 plates and copious text. Cloth, $3.50 net. 
Philadelphia Medical Journal 

"We know of no one work of anything like equal size which covers this important and 
complicated field with the clearness and scientific fidelity of this hand-atlas." 

Golebiewski and Bailey's 
Accident Diseases 

Atlas and Epitome of Diseases Caused by Accidents. 

By Dr. Ed. Golebiewski, of Berlin. Edited, with additions, 
by Pearce Bailey, M. D., Consulting Neurologist to St. Luke's 
Hospital and Orthopedic Hospital, N. Y. 71 colored illustrations 
on 40 plates, 143 text-cuts, 549 pages of text. Cloth, $4.00 net. 
Medical Examiner and Practitioner 

" It is a useful addition to life-insurance libraries, for lawyers, physicians, and for every 
one who is brought in contact with the treatment or consideration of accidents or diseases 
growing out of them, or legal complications flowing from them." 

The "Atlas of Operative Surgery" has been adopted by U. S. Army 



SAUNDERS' MEDICAL HAND-ATLASES 



Atlas and Epitome of External Diseases of the 

Eye. By Dr. 0. Haab, of Zurich. Edited, with additions, by G. E. de 
Schweinitz, M.D., Professor of Ophthalmology in the University of Penn- 
sylvania. Second Revised Edition. With 98 colored illustrations on 48 
plates and 232 pages of text. Cloth, $3.00 net. 

" The work is well done, and is valuable to physicians in general, as well as to ophthal- 
mologists. I shall take pleasure in recommending it." — John E. Weeks, M.D.. Clinical 
Professor 0/ Ophthalmology, University of Bellevue Hospital Medical School, N. Y 

Atlas and Epitome of Internal Medicine and Clinical 

Diagnosis. By Dr. Chr. Jakob, of Erlangen. Edited, with addi- 
tions, by Augustus A. Eshner, M.D., Professor of Clinical Medicine in 
the Philadelphia Polyclinic. With 179 colored figures on 68 plates and 
259 pages of text. Cloth, $3.00 net. 

" Dr. Jakob's work deserves nothing but praise. The information is accurate and up to 
present-day requirements." — British Medical Journal. 

Atlas of Legal Medicine. By Dr. e. von Hofmann, of Vienna. 

Edited, with additions, by Frederick Peterson, M.D., Professor of 
Psychiatry, College of Physicians and Surgeons, New York. With 120 
colored figures on 56 plates and 193 half-tone illustrations. 

Cloth, $3.50 net. 

" It is rare indeed that so large a series of illustrations are found which demonstrate so 
well and so accurately the conditions which they are supposed to represent." — Boston 
Medical and Surgical Journal 

Atlas and Epitome of Diseases of the Larynx. By Dr. 

L. Grunwald, of Munich. Edited, with additions, by Charles P. 
Grayson, M.D., Physician-in- Charge, Throat and Nose Department, 
Hospital of the University of Pennsylvania. With 107 colored figures on 
44 plates, 25 text-illustrations, and 103 pages of text. Cloth, $2. 50 net. 
" Excels everything we have hitherto seen in the way of colored illustrations of diseases 
of the larynx." — British Medical Journal. 

Atlas and Epitome of Operative Surgery. By Dr. o. 

Zuckerkandl, of Vienna. From the Second Revised and Enlarged Ger- 
man Edition. Edited, with additions, by J. Chalmers DaCosta, M.D., 
Professor of the Principles of Surgery and of Clinical Surgery, Jefferson 
Medical College, Philadelphia. Second Edition, Revised and Greatly En- 
larged. With 40 colored plates, 278 text-cuts, and 410 pages of text. 

Cloth, $3.50 net. 

" It may be said that few, if any, books of this description are so comprehensive in their 
scope." — Philadelphia Medical Journal. 

Atlas and Epitome of Syphilis and the Venereal Dis- 
eases. By Prof. Dr. Franz Mracek, of Vienna. Edited, with ad- 
ditions, by L. Bolton Bangs, M.D., late Professor of Genito-Urinary Sur- 
gery, University and Bellevue Hospital Medical College, New York. With 
71 colored plates and 122 pages of text. Cloth, $3.50 net. 

"A glance through the book is almost like actual attendance upon a famous clinic." — 
Journal of the American Medical Association. 

Atlas and Epitome of Skin Diseases. By Prof. Dr. Franz 

Mracek, of Vienna. Edited, with additions, by Henry W. Stelwagon, 
M.D., Clinical Professor of Dermatology, Jefferson Medical College, 
Philadelphia. With 63 colored plates, 39 half-tone illustrations, and 200 
pages of text. Cloth, $3.50 net. 

" The illustrations are very well executed, and the coloring remarkably accurate ; they 
will serve as substitutes for clinical observation." — Medical Record, New York. 

Atlas of Bacteriology and Text-Book of Special Bac- 
teriologic Diagnosis. By Prof. Dr. K. B. Lehmann and Dr. 
R. O. Neumann, of Wiirzburg. From the Second Revised aud Enlarged 
German Edition. Edited, with additions, by G. H. Weaver, M.D., As- 
sistant Professor of Pathology and Bacteriology, Rush Medical College, 
Chicago. Two volumes. Part I. — 632 colored figures on 69 plates. Part 
II. — 511 pages of text, illustrated. Per volume: Cloth, $2.50 net. 

" The illustrations . . . are works of art ; they are true in color and relationship and are 
much superior to the usual photographic reproductions."— Buffalo Medical Journal. 



SAUNDERS' MEDICAL HAND-ATLASES 



Atlas and Epitome of Special Pathologic Histology.— 

By Dr. H. Durck, of Munich. Edited, with additions, by Ludvig Hek- 
toen, M.D., Professor of Pathology, Rush Medical College, Chicago. In 
Two Parts. Part I. — Circulatory, Respiratory, and Gastro-intestinal Tracts. 
Part II. — Liver, Urinary and Sexual Organs, Nervous System, Skin, 
Muscles, and Bones. With 243 colored figures on 122 Plates, and 350 
pages of text. Per part : $3.50 net. 

" The work maintains the high standard of its predecessors. The plates are most beau- 
tifully reproduced and are accurate representations of the microscopic structure of the 
various organs concerned and the changes produced by disease." — The Lancet, London. 

Atlas and Epitome of Diseases Caused by Accidents. 

By Dr. Ed. Golebiewski, of Berlin. Translated and edited, with addi- 
tions, by Pearce Bailey, M.D., Consulting Neurologist to St. Luke's 
Hospital, New York. With 71 colored figures on 40 plates; 143 text- 
illustrations ; 549 pages of text. Cloth, $4.00 net. 

" This volume appeals not only to the medical student and the practitioner, but to the 
medico-legal specialist and accident insurance companies also." — New York Medical 
Journal. 

Atlas and Epitome of Gynecology. By Dr. o. Schaffer, 

of Heidelberg. From the Second Revised and Enlarged German Edition. 
Edited, with additions, by Richard C. Norris, A.M., M.D., Lecturer on 
Clinical and Operative Obstetrics, University of Pennsylvania. With 207 
colored illustrations on 90 plates, 65 text-illustrations, and 308 pages of 
text. $3-5o net. 

" The book contains much valuable material. . . . Rarely have we seen such a valuable 
collection of gynecological plates."— Bulletin of Johns Hopkins Hospital. 

Atlas and Epitome of Labor and Operative Obstet- 
rics. By Dr. O. Schaffer, of Heidelberg. From the Fifth Revised 
and Enlarged German Edition. Edited by j. C. Edgar, M.D., Profes- 
sor of Obstetrics and Clinical Midwifery, Cornell University Medical School. 
With 14 lithographic plates in colors, 139 other illustrations. 32.00 net. 

"A careful study of the plates and drawings is the next best thing to actual clinical 
experience." — Buffalo Medical Journal. 

Atlas and Epitome of Obstetrical Diagnosis and 

Treatment. By Dr. O. Schaffer, of Heidelberg. From the Second 
Revised and Enlarged German Edition. Edited, with additions, by J. C. 
Edgar, M.D., Professor of Obstetrics and Clinical Midwifery, Cornell 
University Medical School. With 122 colored figures on 56 plates, 38 
other illustrations, and 315 pages of text. Cloth, $3.00 net. 

" The illustrations are admirably executed . . . and the text expounds the scientific 
midwifery of to-day." — New York Medical Journal. 

Atlas and Epitome of the Nervous System and its 

Diseases. By Prof. Dr. Chr. Jakob, of Erlangen. From the 
Second Revised and Enlarged German Edition. Edited, with additions, 
by E. D. Fisher, M.D., Professor of Diseases of the Nervous System, 
University and Bellevue Hospital Medical College, New York. 83 plates ; 
215 P a ges of text. $3.50 net. 

" Represents with wonderful accuracy the macroscopic and microscopic anatomy of 
the nervous tissues as found in normal and pathologic conditions." — American 
Medicine. 

Atlas and Epitome of Ophthalmoscopy and Ophthal- 
moscopic Diagnosis. By Dr. O. Haab, of Zurich. From the 
Third Revised and Enlarged German Edition. Edited, with additions, 
by G. E. de Schweinitz, M.D., Professor of Ophthalmology in the Uni- 
versity of Pennsylvania. With 152 colored figures; 82 pages of text. 

Cloth, $3.00 net. 
" Nowhere else can be found such a fine pictorial collection of changes and lesions of the 
eye-fundus as this volume contains."— Journal 0/ the American Medical Association. 



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Atlas and Epitome of Otology. By G. Bruhl, M.D., of Ber- 
lin, with the collaboration of Prof. Dr. A. Politzer, of Vienna. Edited, 
with additions, by S„ MacCuen Smith, M.D. , Clinical Professor of Otol- 
ogy, Jefferson Medical College, Philadelphia. 244 colored figures on 39 
lithographic plates, 99 text-cuts, and 292 pages of text. Cloth, $3.00 net. 

"The most complete of its kind as yet published." — Clarence J. Blake, M.D., Pro- 
fessor of Otology, Harvard Medical School, Boston. 

Atlas and Epitome of Abdominal Hernias. By Privatdo- 

cent Dr. Georg Sultan, of Gottingen. Edited, with additions, by Wil- 
liam B. Coley, M.D., Clinical Lecturer on Surgery, Columbia Univer- 
sity, N. Y. 119 illustrations, 36 in colors; 277 pages of text. 

Cloth, $3.00 net. 

" For the general practitioner and the surgeon it will be a very useful book for refer- 
ence. The book's value is increased by the editorial notes of Dr. Coley." — Boston 
Medical and Surgical Journal. 

Atias and Epitome of Traumatic Fractures and Dislo- 
cations. By Prof. Dr. H. Helferich, of Greifswald. Edited, with 
additions, by Joseph C. Bloodgood, M.D., Associate in Surgery, Johns 
Hopkins University, Baltimore. With 216 colored figures on 64 litho- 
graphic plates, 190 text-cuts, and 353 pages of text. Cloth, $3.00 net. 

" The author has given the anatomy of fractures his special attention. ... It is this 
feature of the work which gives it special value." — University of Pennsylvania Medical 
Bulletin. 

Atlas and Epitome of Diseases of the Mouth, Pharynx, 

and Nose. By Dr. L. Grunwald, of Munich. From the Second 
Revised and Enlarged German Edition. Edited, with additions, by 
James E. Newcomb, M.D., Clinical Instructor in Laryngology, Cornell 
University Medical School. With 102 colored figures on 42 lithographic 
plates, 41 text-cuts, and 219 pages of text. Cloth, $3.00 net. 

"A distinct and valuable addition to the armamentarium of the worker in rhinologic 
fields..' — American Medicine. 

Atlas and Epitome of Human Histology and Micro- 
scopic Anatomy. By Pr. Dr. J. Sobotta, of Wiirzburg. Edited, 
with additions, by G. Carl Huber, M.D., Professor of Histology and 
Embryology, University of Michigan, Ann Arbor. With 214 colored 
figures on 80 plates, 68 text-cuts, and 248 pages of text. Cloth, $4.50 net. 

" The 200 or more colored plates are, above all things, natural, and just as one would 
see them under the microscope."— Indian Lancet, India. 

Atlas and Epitome of Operative Gynecology. By Dr. O. 

Schaffer, of Heidelberg. Edited, with additions, by J. Clarence Web- 
ster, M.D. (Edin.), F.R.C.P.E., Professor of Obstetrics and Gyne- 
cology, Rush Medical College, in affiliation with the University of 
Chicago. With 43 colored figures on 42 lithographic plates, 21 text 
figures, many in colors, and 138 pages of text. #3.00 net. Just issued. 

Atlas and Epitome of General Pathologic Histology. 

By Pr. Dr. Hermann Durck, of Munich. Edited, with additions, by 
Ludvig Hektoen, M.D., Professor of Pathology, Rush Medical College, 
in affiliation with the University of Chicago. With 172 colored figures on 
77 lithographic plates, 36 text-figures, many in colors, and about 450 
pages of text. Ready Shortly. 



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